I.

Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences
that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.

B. Definitions related to sexuality:

Gender identity - sense of femininity or masculinity
- 2-4 yrs/3 yrs gender identity develops.

Role identity – attitudes, behaviors and attributes that differentiate roles

Sex – biologic male or female status. Sometimes referred to a specific sexual

behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female man/ woman. Entity lifelong
dynamic change.
- developed at the moment of conception.

II. Sexual Anatomy and Physiology

A. Female Reproductive System
1. External Structures

a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and
at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tanner Scale Tool - used to determine sexual maturity rating.

Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only

Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly
hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 – darker & curlier at labia
Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an
adult but is not so thick and does not appear to the inner aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh.

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 STAGE 1 STAGE 2 STAGE 3

STAGE 4 STAGE 5

b. Labia Majora - large lips longitudinal fold, extends symphysis pubis to perineum

c. Labia Minora – 2 sensitive structures

 Clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual
arousal (Greek-key)
 Fourchette- Posterior, tapers posteriorly of the labia minora - sensitive to manipulation, torn
during delivery. Site of episiotomy.

d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s
glands.

1. Urinary Meatus – small opening of urethra, serves for urination

2. Skenes glands/or paraurethral gland – mucus secreting subs for lubrication
3. Hymen – covers vaginal orifice, membranous tissue
4. Vaginal orifice – external opening of vagina
5. Bartholene’s glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs –
secrets alkaline subs.
Alkaline – neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus – responsible for acidity of vagina
Carumculae mystiformes-healing of torn hymen

e. Perineum – muscular structure – loc – lower vagina & anus

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 EXTERNAL REPRODUCTIVE ORGANS

2. Internal Structures

a. Vagina – Female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long,
dilated canal.

Rugae – permits stretching without tearing

b. Uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and
weights.

Size - 1 x 2 x 3
Shape: Nonpregnant - pear shaped / pregnant - ovoid
Weight - nonpregnant – 50 - 60 g/pregnant – 1,000g

Pregnant/ Involution of uterus:

4th stage of labor - 1000 g
2 weeks after delivery - 500 g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to original, state 50 – 60 g

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Three parts of the uterus
1. Fundus - upper cylindrical layer
2. Corpus/body - upper triangular layer
3. Cervix - lower cylindrical layer
* Isthmus lower uterine segment during pregnancy
Cornua - junction between fundus & interstitial

Muscular compositions: There are three main muscle layers which make expansion possible in every
direction.

a. Endometrium - inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs
during menstruation.

Decidua - thick layer.

Endometriosis -proliferation of endometrial lining outside uterus. Common site: ovary.

S/Sx: dysmennorhea, low back pain.
Dx: biopsy, laparoscopy
Meds: 1. Danazole (Danocrene) a. to stop menstruation b. inhibit ovulation
2. Lupreulide (Lupron) –inhibit FSH/LH production

b. Myometrium – largest part of the uterus, muscle layer for delivery process
 Its smooth muscles are considered to be the living ligature of the body.
 Power of labor, responsible contraction of the uterus

c. Perimetrium – protects entire uterus

3. Ovaries – 2 female sex glands, almond shaped.

Function: 1. ovulation
2. Production of hormones

4. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to the
ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus.

4 significant segments

1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at ovulation

2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – site of ectopic pregnancy – most dangerous

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FEMALE INERNAL REPRODUCTIVE ORGANS

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B. Male Reproductive System

1. External Structures

a. Penis

 The male organ of copulation and urination. It contains of a body of a shaft consisting of 3
cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the
clitoris in the female – the glans penis.

3 Cylindrical Layers

 2 corpora cavernosa
 1 corpus spongiosum

b. Scrotum
– a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which
contains the testes.
 cooling mechanism of testes
 < 2 degrees C than body temp.
 Leydig’s cell – release testosterone

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2. Internal Structures

The Process of Spermatogenesis – Maturation of sperm

Testes – 900 coiled (½ meter long

at age 13 onwards)
(Seminiferous tubules)

Hypothalamu
Epididymis – 6 meters coiled tubules
s site for maturation of sperm

GnRH

Vas Deferens – conduit for

spermatozoa or pathway of sperm
Ant Pit.
Gland

Seminal vesicle – secretes:

1.) Fructose – glucose has
FSH LF nutritional value.
2.) Prostaglandin – causes reverse
contraction of uterus

Ejaculatory duct – conduit of semen

Fx: Fx: Hormones
Sperm for
Testosterone
Maturation Production Prostate gland- secrets alkaline
substance

Cowpers gland secrets alkaline

substance

Urethra

Male and Female homologues

Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholin's glands
Scrotum Labia Majora

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 III. Basic Knowledge on Genetics and Obstetrics
1. DNA – carries genetic code

2. Chromosomes – threadlike strands composed of hereditary material – DNA

3. Normal amount of ejaculated sperm 3 – 5 cc., 1 tsp

4. Ovum is capable of being fertilized with in 24 – 36

hrs after ovulation

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5. Sperm is viable within 48 – 72 hrs, 2-3
days

6. Reproductive cells divides by the process of meiosis (haploid)

Spermatogenesis – maturation of sperm

Oogenesis – process - maturation of ovum
Gematogenesis – formation of 2 haploid into diploid 23 + 23 = 46 or diploid

7. Age of Reproductivity – 15 – 44y/o

8. Menstruation
Menstrual Cycle – beginning of menstruation to beginning of next menstruation
Average Menstrual Cycle – 28 days
Average Menstrual Period - 3 – 5 days
Normal Blood loss – 50cc or ¼ cup

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 Related terminologies:
Menarche – 1st menstruation
Dysmenorrhea – painful menstruation
Metrorrhagia – bleeding between menstruation
Menorhagia – excessive during menstruation
Amenorrhea – absence of menstruation
Menopause – cessation of menstruation/ average : 51 years old

9. Functions of Estrogen and Progestin

Estrogen “Hormone of the Woman”

Primary function:
development secondary sexual characteristic female.
Others:
1. Inhibit production of FSH ( maturation of ovum)
2. hypertrophy of myometrium
3. Spinnbarkeit & Ferning ( billings method/ cervical)
4. development ductile structure of breast
5. Increase osteoblast activities of long bones
6. Increase in height in female
7. Causes early closure of epiphysis of long bones
8. Causes sodium retention
9. Increase sexual desire

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Progestin “Hormone of the Mother”

Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortuous (twisted)

Secondary Function: uterine contractility (favors pregnancy)

Others: 1. inhibit prod of LH (hormone for ovulation)

2. Inhibit motility of GIT
3. Mammary gland development
4. Increase permeability of kidney to lactose & dextrose causing (+) sugar
5. Causes mood swings in moms
6. Increase BBT

10. Menstrual Cycle

4 phases of Menstrual Cycle

Phases of Menstrual Cycle:

1. Proliferative
2. Secretory
3. Ischemic
4. Menses

Parts of body responsible for menstruation:

1. hypothalamus
2. anterior pituitary gland – master clock of body
3. ovaries
4. uterus

Initial phase – 3rd day – decreased estrogen

13th day – peak estrogen, decrease progesterone
14th day – Increase estrogen, increase progesterone
15th day – Decrease estrogen, increase progesterone

I. On the initial 3rd phase of menstruation, the estrogen level is decreased; this level stimulates the
hypothalamus to release GnRH or FSHRF

II. GnRH/FSHRF – stimulates the anterior pituitary gland to release FSH

Functions of FSH:
1. Stimulate ovaries to release estrogen
2. Facilitate growth primary follicle to become graafian follicle (secrets large amt estrogen &
contains mature ovum.)

III. Proliferative Phase – proliferation of tissue or follicular phase, post mens phase. Pre-ovulatory.
 phase of increase estrogen.

Follicular Phase – causing irregularities in menstruation

Postmenstrual Phase
Preovulatory Phase – phase increase estrogen

IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these
stimulates the hypothalamus to release GnRF on LHRF

1.) Mittelschmerz – slight abdominal pain on L or RQ of abdomen, marks ovulation day.

2.) Change in BBT, mood swing
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 V. GnRF/LHRF stimulates the ant pit gland to release LH.
Functions of LH:
1. (13th day-decreased progesterone) LH stimulates ovaries to release progesterone
2. hormone for ovulation

VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of
graafian follicle on process of ovulation.

VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum
(secrets large amount of progesterone)

VIII. Secretory phase-

Lutheal Phase
Postovulatory Phase - Increased progesterone
Premenstrual

IX. 24th day if no fertilization, corpus luteum degenerate (whitish – corpus albicans)

X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin mens

Fornix- where sperm is deposited

Sperm - small head, long tail, pearly white
Phonones - vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellucida.
Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona
pellucida.

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13
11. Stages of Sexual Responses (EPOR)

Initial responses:

Vasocongestion – congestion of blood vessels

Myotonia – increase muscle tension

1. Excitement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple
erection) – erotic stimuli cause increase sexual tension, lasts minutes to hours.

2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30 seconds
– 3 minutes.

3. Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with
physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 – 10 sec-
most affected are is pelvic area.

4. Resolution – (v/s return to normal, genitals return to pre-excitement phase)

Refractory Period – the only period present in males, wherein he cannot be restimulated for about 10-15
minutes

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STAGES OF SEXUAL RESPONSE

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 IV. Pregnancy & Prenatal Care
A. Fertilization

 The union of the sperm and the mature ovum in the outer third or outer half of the fallopian tube.

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B. Implantation

 Immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days,
during which time rapid cell division (mitosis) is taking place. The developing cells are now called
blastomere and when there are already 16 – 50 blastomeres, it is now termed as morula. In this
morula form, it will start to travel (by ciliary action and peristaltic contraction of the fallopian tube) to
the uterus where it will stay for another 3-4 days. When there is already a cavity formed in the
morula, it is now called blastocyst. Fingerlike projections, called trophoblasts, form around the
blastocysts and these trophoblasts are the one which will implant high on the anterior or posterior
surface of the uterus. Thus implantation, also called nidation, takes place about a week after
fertilization.
 Implantation occurs 8-1 days after fertilization. Implantation must be in the upper portion of the
endometrium. The fertilized ovum will embed itself into the rich endometrial lining.
 General Considerations:
o Once implantation has taken place, the uterine endothelium is now termed as DECIDUA.
o Occasionally, a small amount of vaginal spotting appears with implantation because
capillaries are ruptured by the implanting trophoblasts = Implantation bleeding.
 Implication: this should not be mistaken for the last menstrual period (LMP)

Signs of implantation:

1. Slight pain
2. Slight vaginal spotting
- If with fertilization – corpus luteum continues to function & become source of estrogen &
progesterone while placenta is not developed.

3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion

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 Decidua – thickened endometrium (Latin – falling off)
* Basalis (base) part of endometrium located under fetus where placenta is delivered
* Capsularies – encapsulate the fetus
* Vera – remaining portion of endometrium.

Chorionic Villi- 10 – 11th day, finger life projections

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Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing
placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex
missing digits/toes.

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1. Cytotrophoblast – inner layer or langhan’s layer – protects fetus against syphilis. Life span is 24 wks/6
months. Before 24 weeks critical, might get infected syphilis

2. Synsitiotrophoblast – synsitial layer – responsible production of hormone. Gives rise to the fetal membranes:

a. Amnion – inner most layer which give rise to:

a. Umbilical Cord - FUNIS, whitish grey, 15 – 55cm, 20 – 21 inches.

 Short cord: abruptio placenta or inverted uterus.
 Long cord: cord coil or cord prolapse

“3 vessels”
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood

Wharton’s jelly – protects cord

b. Amniotic Fluid – bag of H2O, clear, odor is mousy/musty, with crystallized forming pattern,
slightly alkaline.

Function of Amniotic Fluid:

1. Cushions fetus against sudden blows or trauma

2. facilitates musculo-skeletal development
3. Maintains temp
4. Prevent cord compression
5. Help in delivery process

 Normal amount of amniotic fluid – 500 to 1000cc

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 Polyhydramnios, hydramnios – “More than 1500cc” - GIT malformation TEF/TEA, increased amt of fluid

 Oligohydramnios – “Less than 500cc” - decrease amt of fluid – kidney disease

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  Kidneys are the source of amniotic fluid in the baby.

Diagnostic Tests for Amniotic Fluid

A. Amniocentesis – N! - Empty bladder before performing the procedure.

Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the
amniotic sac. The fluid is tested for:

1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) – 1st trimester
2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – 3rd
trimester
 Testing time – 36 weeks
 Decreased MSAFP= down syndrome
 Increase MSAFP = spina bifida or open neural tube defect
 Common complication of amniocentesis – infection
 Dangerous complications – spontaneous abortion
 3rd trimester- pre term labor
 Important factor to consider for amniocentesis- needle insertion site
 Aspiration of yellowish amniotic fluid – jaundice baby
 Greenish – meconium

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B. Amnioscopy – direct visualization or exam to an intact fetal membrane.

C. Fern Test - determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured
amniotic fluid)

D. Nitrazine Paper Test – differentiate amniotic fluid & urine.

Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.

b. Chorion – where placenta is developed

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Lecithin Sphingomyelin L/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test – amniotic + saline & shake

Foam test
Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity

b.1 Placenta – (Secundines) Greek – pancake, combination of chorionic villi + decidua basalis.
Size: 500g or ½ kg
 1 inch thick & 8” diameter

Functions of Placenta:

1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion

2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to
lower. If mom hypoglycemic, fetus hypoglycemic.

3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.

4. Circulating system – achieved by selective osmosis

5. Endocrine System – produces hormones

 Human Chorionic Gonadotropin – maintains corpus luteum alive. It is also called

the basis of pregnancy.
 Human placental Lactogen or somatomammotropin Hormone – for mammary
gland development. Has a diabetogenic effect – serves as insulin antagonist
 Relaxin Hormone- causes softening joints & bones
 estrogen
 progestin

6. It serves as a protective barrier against some microorganisms – HIV,HBV

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 C. Fetal Stage “Fetal Growth and Development”
 Zygote – from fertilization till the 14th day.
 Embryo – 15th day to 2 months
 Fetus – From 2 mos. Until birth

Days of normal pregnancy - 266 – 280 days or equivalent to 10 lunar months or 9 Calendar months
Normal Pregnancy in weeks – 37 to 42

Differentiation of Primary Germ layers

* Endoderm
1st week endoderm – primary germ layer
Thyroid – for basal metabolism
Parathyroid - for calcium
Thymus – development of immunity
Liver – lining of upper RT & GIT

* Mesoderm – development of heart, musculoskeletal system, kidneys and repro organ.

* Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus &
mouth

First trimester:

1st month - Brain & heart development

GIT& Respiratory Tract – remains as single tube

1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mom due to hypoglycemic effect
 Food of brain – glucose
 Complex CHO – pregnant womans food (potato)

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Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month
3. Sex organ formed
4. Meconium is formed

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 Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard – Doppler – 10 – 12 weeks
4. Sex is distinguishable

Health Teaching!

 Avoid Teratogens such as smoking, drugs, alcohol, radiation and diseases.

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Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A. Drugs:

Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing
& deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia or pocomelia, absence of extremities
Steroids – cleft lip or palate
Lithium – congenital malformation

B. Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by
microcephaly

C. Smoking – low birth rate

D. Caffeine – low birth rate
E. Cocaine – low birth rate, abruption placenta

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TORCH (Terratogenic) Infections – viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through
birth canal and adversely affect fetal growth and development. These infections are often characterized by
vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement).
In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the
fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.

T – Toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat
O – Others. Hepa A or infectious heap – oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids
Syphilis
R – Rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10
<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant
for 3 months. Vaccine is terratogenic
C – Cytomegalo virus
H – Herpes simplex virus

Second Trimester:
FOCUS – length of fetus

Fourth Month

1. Lanugo begins to appear

2. Fetal heart tone heard fetoscope, 18 – 20 weeks
3. Buds of permanent teeth appear

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Fifth Month

1. Lanugo covers body

2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi
5. Fetal heart tone heard with or without instrument

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Sixth Month

1. eyelids open
2. wrinkled skin
3. vernix caseosa present

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Third trimester: Period of most rapid growth.
FOCUS: weight of fetus

Seventh Month – development of surfactant

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Eighth Month

1. Lanugo begin to disappear

2. Subcutaneous fat deposits
3. Nails extend to fingers

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Ninth Month

1. Lanugo & vernix caseosa completely disappear

2. Amniotic fluid decreases

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 Tenth Month – bone ossification of fetal skull

D. Normal Adaptations to Pregnancy

A. Systemic Changes

1. Cardiovascular System
 Increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood
 Easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis – due to
hyperemia of nasal membrane palpitation,
 Palpitations due to stimulation of Sympathetic nerves.

Physiologic Anemia – pseudo anemia of pregnant women

Normal Values

Hct 32 – 42%
Hgb 10.5 – 14g/dL

Criteria

1st and 3rd trimester - pathologic anemia if lower

HCT should not be 33%, Hgb should not be < 11g/dL

2nd trimester – Hct should not < 32%

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 Hgb Shdn't < 10.5% pathologic anemia if lower

Pathogenic Anemia
 Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of
pregnant women.
o Assessment reveals:
 Pallor, constipation
 Slowed capillary refill time (CRT)
 Concave fingernails (late sign of progressive anemia) due to chronic hypoxia

Nursing Care:
 Nutritional instruction – kangkong, liver due to ferritin content, green leafy vegetables such as
alugbati,saluyot, malunggay, horseradish, and ampalaya.
 Parenteral Iron (Imferon) – severe anemia, give IM, Z tract- if improperly administered, it will result
in hematoma.
 Oral Iron supplements (ferrous sulfate 0.3 gm, 3 times a day) empty stomach 1 hr before meals or
2 hrs after, black stool, constipation
 Monitor for hemorrhage

Alert:
 Iron from red meats is better absorbed iron form other sources
 Iron is better absorbed when taken with foods high in Vit C such as orange juice
 Higher iron intake is recommended since circulating blood volume is increased and heme is
required from production of RBCs

Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level.

Varicosities – pressure of uterus

 use support stockings, avoid wearing knee high socks
 use elastic bandage – lower to upper

Vulbar varicosities - painful, pressure on gravid uterus, to relieve- position – side lying with pillow under
hips or modified knee chest position

Thrombophlebitis – presence of thrombus at inflamed blood vessel

- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate

Outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion

Milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Management:

1.) Bed rest

2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate
6.) Avoid aspirin! Might aggravate bleeding.

2. Respiratory System Changes – common problem SOB due to enlarged uterus & increase O2
demand
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 Management:
o Position - lateral expansion of lungs or side lying position.

3. Gastrointestinal System Changes – 1st trimester change

 Morning Sickness – nausea & vomiting due to

increase HCG.
o Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small
frequent feeding. Vomiting in pregnancy – hyperemesis gravidarum.
o Hyperemesis Gravidarum – excessive nausea and vomiting which persists beyond 3
months; may result in Metabolic alkalosis, F&E imbalance
 Primary Management
 Replace fluids.
 Monitor I&O
 Complete bed rest is also a complete aspect of treatment

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 Constipation – progesterone responsible for constipation.
o Increase fluid intake, increase fiber diet
o Fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
o Except guava – has pectin that’s constipating
o Encourage/Increase exercise
o Avoid mineral oil – It interferes with absorption of fat soluble vitamins.
 Flatulence – avoid gas forming food – cabbage
 Heartburn – or pyrosis – reflux of stomach content to esophagus
o small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body
mechanical
 Increase salivation – ptyalsim – Management is mouthwash
 Hemorrhoids – pressure of gravid uterus.
o Management is hot sitz bath for comfort.

4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying
position.

Heat Acetic Acid test – albumin in urine

Benedict’s test – sugar in urine

5. Musculoskeletal System Changes

Lordosis – pride of pregnancy

Waddling Gait – awkward walking due to hormone relaxin – causes softening of joints & bones
Prone to accidental falls – wear low heeled shoes
Leg Cramps – causes: prolonged standing, over fatigue, Ca & phosphorus imbalance (#1 cause while
pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus
Management: Increase Ca diet – milk (Increase Ca & phosphorus) -1pint/day or 3-4 servings/day.
Cheese, yogurt, head of fish,
 Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.
 Vit D for increased Ca absorption

6. Emotional responses

Psychological Adaptation to Pregnancy (Emotional response of mom – Reva Rubin theory)

First Trimester: No tangible signs & symptoms, surprise, ambivalence, denial – sign of maladaptation to
pregnancy.

 Developmental task is to accept biological facts of pregnancy

 Focus: bodily changes of pregnancy/nutrition

Second Trimester – Tangible Signs & Symptoms. mom identifies fetus as a separate entity – due to
presence of quickening, fantasy.

 Developmental task – accept growing fetus as baby to be nurtured.

 Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of baby

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  Development task: prepare of birth & parenting of child. HT: responsible parenthood ‘baby’s
Layette” – best time to do shopping.
 Most common fear – let mom listen to FHT to allay fear
 Lamaze classes

B. Local Changes

Local change: Vagina:

V – Chadwick’s sign – blue violet discoloration of vagina

C – Goodell's sign – change of consistency of cervix (softening)
I/U – Hegar's – change of consistency of isthmus (lower uterine segment)- softening of the uterus

LEUKORRHEA – whitish gray, mousy odor discharge

ESTROGEN – hormone, responsible for leukorrhea

OPERCULUM – mucus plug to seal out bacteria.
PROGESTERONE – hormone responsible for operculum
PREGNANT – acidic to alkaline change to protect bacterial growth (virginities)

Problems Related to the Change of Vaginal Environment:

a. Vaginitis – caused by trichomonas vaginalis due to alkaline environment of vagina of pregnant mother.
Flagellated protozoa – wants alkaline
Signs & Symptoms:
 Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
 Management:
FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1st trimester
1. treat dad also to prevent reinfection
2. no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O: 1 tbsp white vinegar

b. Moniliasis or candidiasis due to candida albecans, fungal infection.

Signs & Symptoms:

39
  Color – white cheese like patches adheres to walls of vagina.
 Management – antifungal – Nistatin, Gentian violet, cotrimozaxole, canesten

Facts:

40
  Gonorrhea -Thick purulent discharge

 Vaginal warts - condiloma acuminata due to papilloma virus. Management is Cauterization.

2. Abdominal Changes – striae gravidarium (stretch marks) due enlarging uterus-destruction of

subcutaneous tissue – avoid scratching, use coconut oil, umbilicus is protruding.

3. Skin Changes – brown pigmentation nose chin, cheeks – chloasma/melasma due to increased
melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus

4. Breast Changes – increase hormones, color of areola & nipple. Pre colostrums present by 6 weeks,
colostrums at 3rd trimester

Breast self exam - 7 days after menstruation –– supine with pillow at back
 Quadrant B – upper outer – common site of cancer

Test to determine Breast Cancer:

1. Mammography – 35 to 49 yrs once every 1 to 2 yrs

50 yrs and above – 1 x a yr

5. Ovaries – rested during pregnancy

6. Signs & symptoms of Pregnancy

A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of
pregnancy . Subjective
B. Probable – signs observed by the members of health team. Objective
C. Positive Signs – undeniable signs confirmed by the use of instrument.

* + HCG – sign of H mole

- Trans vaginal ultrasound. Empty bladder
- Ultrasound – full bladder

Placental grading – rating/grade

o – Immature
1 – Slightly mature
2 – Moderately mature
3 – Placental maturity

What is deposited in placenta which signify maturity - there is calcium

Presumptive Probable Positive

 Breast changes  Goodel's- change of consistency of cervix  Ultrasound
 Urinary frequency  Chadwick’s- blue violet discoloration of vagina evidence
 Fatigue  Hegar's- change of consistency of isthmus (sonogram) full
 Amenorrhea  Elevated BBT – due to increased progesterone bladder
 Morning sickness  Positive HCG or (+)preg test  Fetal heart tone
 Enlarged uterus  Ballottement – bouncing of fetus when lower uterine is  Fetal movement
 Chloasma tapped sharply  Fetal outline
 Linea niagra  Enlarged abdomen  Fetal parts palpable
 Increased skin  Braxton Hicks contractions – painless irregular
pigmentation contractions
 Striae gravidarium
41
 Quickening

E. The Pre-Natal Visit

A. Diagnosis of Pregnancy

1. Urine Examination

 Urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best
to get urine exam.
 Elisa test – test for pregnancy detects beta subunit of HCG as early as 7 – 10days
 Home pregnancy kit – do it yourself

B. Components of Prenatal Visit

1. History taking

Frequency of Visit: 1st 7 months – 1x a month

8 – 9 months – 2 x a month
10 – Once a week
Post term 2 x a week

a. Personal data – name, age (high risk < 18 & > 35 yrs old) record to determine high risk – HBMR.
 Home based mother record. Sex (pseudocyesis or false pregnancy on men & women)
 Couvade syndrome – dad experiences what mother goes through – lihi
 Address, civil status, religion, culture & beliefs with respect, non judgmental
 Occupation – financial condition or occupational hazards, education background – level
knowledge

b. Baseline Data: V/S especially BP, monitor weight (increase weight – 1st sign preeclampsia)

Weight Monitoring

First Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month)

Second trimester: normal weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: normal weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)
Minimum wt gain – 20 – 25 lbs
Optimal wt gain – 25 – 35 lbs

c. Obstetrical Data:

nullipara – no pregnancy
Gravida - # of pregnancy
Para - # of viable pregnancy

Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.

Age of viability – 20 to 24 weeks

Term – 38 to 42 weeks
Preterm – 20 to 37 weeks
Abortion – less than 20 weeks

42
Sample Cases:

1 – abortion G2P0(0010)
1 – 2nd months
G–2
P–0

1 – 40th AOG GTPA L

1 – 36th AOG 612 2 4
2 – Miscarriage
1 – Twins 35 AOG
1 – 4th month G6 P3

1 – 39th week
1 – Miscarriage GP GTPAL
1 – Stillbirth 33 AOG (considered as para) 42 4111 1
1 – Pregnant, 3rd wk

d. Medical Data – is there a history of kidney, cardiac or liver diseases, hypertension, tuberculosis, or
sexually transmitted diseases.

2. Assessment

a. Physical Examination

Examine teeth: sign of infection

“Danger signs of Pregnancy”

C - Chills/ fever - infection

Cerebral disturbances (headache – preeclampsia)

A – Abdominal pain (epigastric pain – aura of impending convulsions)

B – Board like abdomen – abruptio placenta

Increase BP – HPN/HTN
Blurred vision – preeclampsia
Bleeding – 1st trimester, abortion, ectopic preg/2nd – H mole, incompetent cervix
3rd – placental anomalies

S – Sudden gush of fluid – PROM (premature rupture of membrane) prone to inf.

E – Edema to upper ext. (preeclampsia)

b. Pelvic Examination

Pelvic Examination – internal exam

1. empty bladder
2. universal precaution

EXT OS of cervix – site for getting specimen

- Site for cervical cancer

Pap smear – cervical cancer

43
  composed of squamous columnar tissue

Result:

Class I - normal
Class IIA – cytology but no evidence of malignancy
B – suggestive of inflammation
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy

Stages of Cervical Cancer

Stage 0 – carcinoma in situ

1 – Cancer confined to cervix
2 - Cancer extends to vagina
3 – Pelvis metastasis
4 – Affection to bladder & rectum

Leopold’s Maneuver

Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an
estimate of the size, and number of fetuses, position, fetal back & fetal heart tone
 Use palm! Warm palm

Preparation for the mother:

44
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)

Procedure:

1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right
hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness
of the part to determine presentation

2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart sound)
where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff
fundic soufflé (FHR) & uterine soufflé.
Uterine soufflé – maternal H rate

3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.

Assess whether the presenting part is engaged in the pelvis) Alert : if the head is engaged it will not be
movable).

4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands, assess
the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude –
relationship of fetus to 1 another.

When the brow is on the same side as the back, the head is extended. When the brow is on the same
side as the small parts, the head will be flexed and vertex presenting.

Attitude – relationship of fetus to a part – or degree of flexion

Full flexion – when the chin touches the chest

45
46
47
c. Urine Examination

Heat Acetic Acid test –To test for protein in the urine
 Denatured Alcohol is used, test tube, test tube holder, 10 drops of urine, 3-5 ml of acetic
acid.
 After heating for 3 minutes
o Clear (-) for albumin
o Cloudy (+) for albumin precipitate

Benedict’s test – test for sugar

 5 ml of solution, 10 gtts of urine
 Results:
o B – Blue (-)
o G - Olive Green (+1) – 1 mol. Of sugar
o Y – Yellow – (+2) – 2 mol. Of sugar
o O – Orange – (+3) – 3 mol. Of sugar
o R – Red – (+4) – 4 mol. Of sugar

 Both solution may expire if Acetic Acid (Brown), Benedicts (Violet), then discard.

3. Important Estimates

a. Estimates of Age of gestation (AOG)

 Naegele’s Rule – use to determine expected date of delivery

Get LMP -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar

M D Y +9 +7 no year

LMP Jan 25, 04

+9 +7
10 / 32 / 04
- 1
Add 1 month to month
11/31/04 EDD

 McDonald’s Rule – to determine age of gestation IN WEEKS

FUNDIC HT X 7/8=AOG in WK

Fundic Ht X 7 = AOG in weeks

8
Fr sypmhyis pubis to fundus 24 X 7 =21 wks
8
 Bartholomew’s Rule – to determine age of gestation by proper location of fundus at abdominal
cavity.

3 months – above symphysis pubis

5 months – level of umbilicus
9 months – below xyphoid process
10 months – level of 8 months due to lightening

b. Haases rule – to determine length of the fetus in cm.

Formula: 1st ½ of preg , square @ month

48
 2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg
5 x 5 = 25 cm

6x5= 30 cm
7x5= 35 cm 2nd ½ of preg
8x5= 40 cm
9x5= 45 cm

4. Health Teachings

a. Nutrition – do nutritional assessment – daily food intake

High risk moms:

1.Pregnant teenagers – low compliance to heath regimen.

2.Extremes in wt – underweight, over wt – candidate for HPN, DM
3.Low socio – economic status
4.Vegetarian mom – decrease CHON – needs Vit. B12 – cyanocobalamin – formation of folic acid –
needed for cell DNA & RBC formation. (Decrease folic acid – spinal bifida/open neural tube defect)
How many Kcal CHO x4, CHON x4, fats x 9

Recommended Nutrient Requirement that increases During Pregnancy

Nutrients Requirements Food Source

Calories
Essential to supply energy for
- increased metabolic rate
- utilization of nutrients
- protein sparing so it can be
used for
- Growth of fetus
- Development of structures
required for pregnancy
including placenta, amniotic
fluid, and tissue growth.
300 calories/day above the Caloric increase should reflect
prepregnancy daily requirement - Foods of high nutrient value such
to maintain ideal body weight as protein, complex carbohydrates
and meet energy requirement to (whole grains, vegetables, fruits)
activity level - Variety of foods representing
- Begin increase in second foods sources for the nutrients
trimester requiring during pregnancy
- Use weight – gain pattern as - No more than 30% fat
an indication of adequacy of
calorie intake.
- Failure to meet caloric
requirements can lead to
ketosis as fat and protein
are used for energy; ketosis
has been associated with
fetal damage.

Protein 60 mg/day or an increase of Protein increase should reflect

Essential for:
- Fetal tissue growth
- Maternal tissue growth
including uterus and breasts
- Development of essential
pregnancy structures
- Formation of red blood cells
and plasma proteins
10% above daily requirements
for age group
Adolescents have a higher
protein requirement than mature
women since adolescents must
supply protein for their own
growth as well as protein t meet
- Lean meat, poultry, fish
- Eggs, cheese, milk
- Dried beans, lentils, nuts
- Whole grains
* vegetarians must take note of the
amino acid content of CHON foods
consumed to ensure ingestion of
sufficient quantities of all amino acids

49
* Inadequate protein intake has
been associated with onset of
pregnancy induces hypertension
(PIH)
Calcium-Phosphorous
Essential for
- Growth and development of
fetal skeleton and tooth
buds
- Maintenance of
mineralization of maternal
bones and teeth
- Current research is :
Demonstrating an association
between adequate calcium intake
and the prevention of pregnancy
induce hypertension
Iron
Essential for
- Expansion of blood volume and requirement
red blood cells formation
- Establishment of fetal iron
stores for first few months of life
Zinc
Essential for
* the formation of enzymes
* maybe important in the
prevention of congenital
malformation of the fetus.
the pregnancy requirement
Calcium increases of
- 1200 mg/day representing
an increase of 50% above
prepregnancy daily
requirement.
- 1600 mg/day is
recommended for the
adolescent. 10 mcg/day of
vitamin D is required since it
enhances absorption of both
calcium and phosphorous
30 mg/day representing a
doubling of the pregnant daily
- Begin supplementation at
30- mg/day in second
trimester, since diet alone is
unable to meet pregnancy
requirement
- 60 – 120 mg/day along with
copper and zinc
supplementation for women
who have low hemoglobin
values prior to pregnancy or
who have iron deficiency
anemia.
- 70 mg/day of vitamin C
which enhances iron
absorption
- inadequate iron intake
results in maternal effects –
anemia depletion of iron
stores, decreased energy
and appetite, cardiac stress
especially labor and birth
- fetal effects decreased
availability of oxygen
thereby affecting fetal
growth
* iron deficiency anemia is the
most common nutritional
disorder of pregnancy.
15mcg/day representing an
increase of 3 mg/day over
prepreganant daily
requirements.
Calcium increases should reflect:
- dairy products : milk, yogurt, ice
cream, cheese, egg yolk
- whole grains, tofu
- green leafy vegetables
- canned salmon & sardines w/
bones
- Ca fortified foods such as orange
juice
- Vitamin D sources: fortified milk,
margarine, egg yolk, butter, liver,
seafood
Iron increases should reflect
- liver, red meat, fish, poultry,
eggs
- enriched, whole grain cereals
and breads
- dark green leafy vegetables,
legumes
- nuts, dried fruits
- vitamin C sources: citrus fruits
& juices, strawberries,
cantaloupe, broccoli or
cabbage, potatoes
- iron from food sources is
more readily absorbed when
served with foods high in vit C
Zinc increases should reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains, legumes, nuts
50
Folic Acid, Folacin, Folate 400 mcg/day representing an Increases should reflect
Essential for increase of more then 2 times - liver, kidney, lean beef, veal
- formation of red blood cells the daily prepregnant - dark green leafy vegetables,
and prevention of anemia requirement. 300mcg/day broccoli, legumes.
- DNA synthesis and cell supplement for women with low - Whole grains, peanuts
formation; may play a role folate levels or dietary
in the prevention of neutral deficiency
tube defects (spina bifida), 4 servings of grains/day
abortion, abruption
placenta
Additional Requirements Increased requirements of pregnancy
Minerals can easily be met with a balanced diet
- iodine 175 mcg/day that meets the requirement for
- Magnesium 320 mg/day calories and includes food sources
- Selenium 65 mcg/day high in the other nutrients needed
during pregnancy.
Vitamins Vit stored in body. Taking it not
E 10 mg/day needed – fat soluble vitamins. Hard to
Thiamine 1.5 mg/day excrete.
Riborlavin 1.6 mg/day
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day

b. Sexual Activity

a.) should be done in moderation

b.) should be done in private place
c.) mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism

Changes in sexual desire:

a.) 1st tri – decrease desire – due to bodily changes

b.) 2nd trimester – increased desire due to increase estrogen that enhances lubrication
c.) 3rd trimester – decreased desire

Contraindication in sex:

1. Vaginal spotting
1st trimester – threatened abortion
2nd trimester– placenta previa
2. Incompetent cervix
3. Preterm labor
4. Premature rupture of membrane

c. Exercises – to strengthen muscles used during delivery process

Principles of exercise
 Done in moderation
 Must be individualized

Walking – best exercise

51
Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor

Tailor Sitting – 1 leg in front of other leg (Indian seat)

Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position

 shoulder circling exercise- strengthen chest muscles

 pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture
 Arch back – standing or kneeling. Four extremities on floor

Kegel Exercise – strengthen pulococcygeal muscles

 As if hold urine, release 10x or muscle contraction

Abdominal Exercise – strengthens muscles of abdominal – done as if blowing candle

d. Childbirth Preparation:

Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that
can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth
experience.

“Psychophysical”

1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery
process. Based on imitation of nature.

Features:

1.) Darkened room

2.) Quiet environment
3.) Relaxation technique
4.) Closed eye & appearance of sleep

2. Grantly Dick Read Method – fear leads to tension while tension leads to pain

“Psychosexual”

1. Kitzinger method – preg, labor & birth & care of newborn is an important turning pt in woman’s life
cycle
 flow with contraction than struggle with contraction

Psychoprophylaxis – prevention of pain

2. Lamaze: Dr. Ferdinand Lamaze

Requirement - discipline, conditioning & concentration. Husband is coach

Features:
1. Conscious relaxation
2. Cleansing breathe – inhale nose, exhale mouth
3. Effleurage – gentle circular massage over abdominal to relieve pain
4. imaging – sensate focus

Different Methods of delivery:

52
1.) birthing chair – bed convertible to chair – semifowlers
2.) birthing bed – dorsal recumbent pos
3.) squatting – relives low back pain during labor pain
4.) Leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.
5.) Birth under H20 – bathtub – labor & delivery – warm water, soft music.

5. Tetanus Immunization

 Prevents tetanus neonatorum

 Mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

TT1 – any time during pregnancy

TT2 – 4 wks after TT1 – 3 yrs protection
TT3 – 6 months after TT2 – 5 yrs protection
TT4 – 1 yr after TT3 – 10 yrs protection
TT5 – yr after TT4 – lifetime protection

6. Assessment of fetal well being

A. Daily Fetal Movement Counting (DFMC) –begin 27 weeks

Mom- begin after meal - breakfast

(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal
movement, noting how long it takes to count 10 fetal movements (FMs)

(2) Expected findings – 10 movements in 1 hour or less

(3) Warning signs

a.) more then 1 hour to reach 10 movements

b.) less then 10 movements in 12 hours (non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous

Movement alarm signals - < 3 FMs in 12 hours

(4) Warning signs should be reported to healthcare provider immediately; often require further testing.
Examples: nonstress test (NST), biographical profile (BPP)

B. Nonstress test – to determine the response of the fetal heart rate to activity

Indication – pregnancies at risk for placental insufficiency

Postmaturity

a.) pregnancy induced hypertension (PIH), diabetes

b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition

Procedure:

Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external
monitor is applied to document fetal activity; mother activates the “mark button” on the electronic
monitor when she feels fetal movement.

53
 Attach external noninvasive fetal monitors

1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
 if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through
abdomen
 if no FM after 1 hour further testing may be indicated, such as a CST

Result:

Nonreactive
Nonstress
Not Good

Reactive
Responsive is
Real Good

Interpretation of results

A. Reactive result

1. Baseline FHR between 120 and 160 beats per minute

2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15
seconds in a 10 to 20 minute period as a result of FM
3. Good variability – normal irregularity of cardiac rhythm representing a balanced interaction
between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous
system; noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system

B. Nonreactive result

1. Stated criteria for a reactive result are not met

2. Could be indicative of a compromised fetus.

 Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test
(CST)

V. Labor & Delivery

A. Admitting the laboring Mother:
Personal Data: name, age, address, etc
Baseline Data: v/s especially BP, weight
Obstetrical Data: Gravida - # of pregnancy, Para- #viable pregnancy, 22 – 24 wks
Physical Exams, Pelvic Exams

B. Basic knowledge in Intrapartum:

1. Theories of the Onset of Labor

54
 1.) Uterine stretch theory (any hallow organ stretched, will always contract & expel its content) –
contraction action
2.) Oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin
3.) Prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction
4.) Progesterone theory – before labor, decrease progesterone will stimulate contractions & labor
5.) Theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to
contraction – onset labor).

2. The 4 P’s of labor

1. Passenger

a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.

Bones – 6 bones
S – Sphenoid
E – Ethmoid
T – Temporal Bones (2)
F – Frontal/Sinciput
O – Occuputal/occiput
P – Parietal (2)

Measurement fetal head:

1. Transverse diameter
a. biparietal – 9.25cm, largest transverse
b. bitemporal - 8 cm
c. bimastoid 7cm smallest transverse

2. Anteroposterior diameters
a. suboccipitobregmatic - 9.5 cm, complete flexion, smallest AP
b. occipitofrontal - 12cm partial flexion
c. occipitomental – 13.5 cm hyper extension, submentobragmatic - face presentation

55
56
Sutures – intermembranous spaces that allows molding.
 Sagittal suture – connects 2 parietal bones
 Coronal suture – connect parietal & frontal bone (crown)
 Lambdoidal suture – connects occipital & parietal bone

Molding: the overlapping of the sutures of the skull to permit passage of the head to the pelvis; usually
reserved by 3 days after birth.

Fontanels: membrane - covered spaces at the junction of the main suture lines.

a. Anterior fontanels – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18

months after birth – close
b. Posterior fontanel or lambda – triangular shape, 1 x 1 cm. closes – 2 – 3 months.

57
2. Passageway

Mom

1.) < 4’9” tall

2.) < 18 years old
3.) Underwent pelvic dislocation

4 main pelvic types:

1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider

Pelvimetry – x ray of the pelvis to determine if the fetus can pass through NSD.

Pelvis is a bony ring interposed between the trunk and the thigh. It serves to both support and protect
the reproductive and other pelvic organs.

Structures :

It composed of four bones: 2 innominate bones or hip bones, 1 sacrum and 1 coccyx.

 The HIP BONES are divided into 3 parts :

58
 1. Ilium – the largest portion of the bones forming the upper and back part of the pelvis.

 iliac crest – the curved boarder which gives grace to the female figure.
 anterior superior and posterior superior iliac spine – the terminal point of ilium.

2. Ischium - the lower part below the hip joint.

 ischial tuberosities – a pair of large prominence at the lower most part of the ischia on which
the bone rests when in sitting position.
 ischial spine – a pair of small projections.

3. Pubis - the front part of the hip bone.

 symphysis pubis – point of union of 2 pubic bones.

 pubic arch – the angle formed by the union of inferior rami of the pubic bones.
 obturator foramen – a ring formed by the union of superior and inferior rami of the pubis.

4. SACRUM - wedge- shaped bone composed of 5 sacral vertebral. It serves as the back part
of the pelvis.

COCCYX – a small movable bone consists of 4 coccygeal vertebral. It forms as tail end to the
spine.

Important Measurements

1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis
pubis.

Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and
superior margin of the symphysis pubis.

Measurement: 11.0 cm

3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter – transverse diameter of the pelvic outlet.

Ischial tuberosity – approximated with use of fist – 8 cm & above.

3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor

a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity

4. Psyche/Person – psychological stress when the mother is fighting the labor experience

a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
59
 5. Position – Maternal Position

C. Pre-Eminent Signs of Labor

Signs & Symptoms:
 Shooting pain radiating to the legs
 Urinary freq.
1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions – painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase
epinephrine
4. Ripening of the Cervix – butter soft
5. decreased body wt – 1.5 – 3 lbs
6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea
7. Rupture of Membranes – rupture of water. Check FHT

Premature Rupture of Membrane (PROM) - do IE to check for cord prolapse

Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations

Nursing Care:

 Administer Analgesics (Morphine)

 Attempt manual rotation for ROP or LOP – most common malposition
 Bear down with contractions
 Adequate hydration – prepare for CS
 Sedation as ordered
 Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina.

Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina

60
Nursing Care:
 Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery &
prevent cord compression causing cerebral palsy.
 Slip cord away from presenting part
 Count pulsation of cord for FHT
 Prep mom for CS

Positioning – trendelenberg or knee chest position

Emotional support
Prepare for Cesarean Section

Difference between True Labor and False Labor

False Labor True Labor

Irregular contractions
No increase in intensity
Pain – confined to abdomen
Pain – relived by walking
No cervical changes
Contractions are regular
Increased intensity
Pain – begins lower back radiates to abdomen
Pain – intensified by walking
Cervical effacement & dilatation * major sx
of true labor.

Duration of Labor
Primipara – 14 hrs & not more than 20 hrs
Multipara – 8 hrs & not > 14 hrs

Effacement – softening & thinning of cervix. Use % in unit of measurement

Dilation – widening of cervix. Unit used is c

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Nursing Interventions in Each Stage of Labor

2 segments of the uterus

1. Upper uterine - fundus

2. lower uterine – isthmus

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D. Stages of Labor

1. First Stage: onset of true contractions to full dilation and effacement of cervix.

Latent Phase:

Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can communicate

Frequency: every 5 – 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
3. Breathing – chest breathing

Active Phase:

Assessment: Dilations 4 -8 cm
Intensity: moderate Mom - fears losing control of self
Frequency – q 3-5 mins lasting for 30 – 60 seconds

Nursing Care:
M – edications – have meds ready
A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D – dry lips – oral care (ointment)
Dry linens
B – Abdominal breathing

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Transitional Phase:
Intensity: strong Mom – mood changes with hyperesthesia

Assessment: Dilations 8 – 10 cm
Frequency q 2-3 min contractions
Durations 45 – 90 seconds

Hyperesthesia – increase sensitivity to touch, pain all over

Health Teaching: sacral pressure on lower back to inhibit transmission of pain

 Keep informed of progress
 Controlled chest breathing

Nursing Care:
T – ires
I – nform of progress
R – estless support her breathing technique
E – ncourage and praise
D – iscomfort

Pelvic Exams

Effacement
Dilation

a. Station – landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if (-) floating

- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning – occurs at 2nd stage of labor

64
b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother
 spine of mom and spine of fetus

Two types:

b.1. Longitudinal Lie ( Parallel)

Cephalic - Vertex – complete flexion

Face
Brow Poor Flexion
Chin

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“Breech”
Complete Breech – thigh breast on abdomen, breast lie on thigh
Incomplete Breech – thigh rest on abdominal
Frank – legs extend to head
Footling – single, double
Kneeling

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b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.

Possible Fetal Positions:

“Vertex”

Occiput – LOA Left Occiput Anterior (most common and favorable position) – side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful

“Breech”

LSA – Left Sacroanterior

LSP – Left sacroposterior

“Shoulder/acromniodorso”

LADA – Left acromiodorso anterior

LADP – Left acromiodorso posterior

“Chin / Mento”
LMA – Left mento anterior
LMO – left mento posterior

67
Monitoring the Contractions and Fetal heart Tone

Spread fingers lightly over fundus – to monitor contractions

Parts of contractions:

Increment or crescendo – beginning of contractions until it increases

Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions until it decreases
Duration – beginning of contractions to end of same contraction
Interval – end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction

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 Contraction – vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve – 60 sec o2 for fetus during contractions

Duration of contractions shouldn’t >60 sec
Notify MD

Mom has headache – check BP, if same BP, let mom rest. If BP increases, notify MD –preeclampsia

Health teachings
1.) Ok to shower
2.) NPO – GIT stops function during labor if with food- will cause aspiration
3.) Enema administer during labor
a.) To cleanse bowel
b.) Prevent infection
c.) Sims position/side lying

12 – 18 inch – ht enema tubing

Check FHT after administration of enema

Normal FHT= 120-160

Signs of fetal distress

1.) <120 & >160

2.) meconium stain amnion fluid
3.) Fetal thrushing – hyperactive fetus due to lack O2

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 – 8 multi – bring to delivery room

10cm primi – bring to delivery room

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 Lithotomy position – put legs same time up
Bulging of perineum – sure to come out
Breathing – panting (teach mom)

Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, and shorten 2nd stage of
labor.
Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum
(urethroanal fistula)
Mediolateral – more bleeding & pain, hard to repair, slow to heal
 use local or pudendal anesthesia.

Ironing the perineum – to prevent laceration

Modified Ritgens maneuver – place towel at perineum

1.) To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled.
Pull shoulder down & up. Check time, identification of baby.

Mechanisms of labor

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion

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Three parts of Pelvis

1. Inlet – AP diameter narrow, transverse diameter wider

2. Cavity

Two Major Divisions of Pelvis

1. True pelvis – below the pelvic inlet

2. False pelvis – above the pelvic inlet; supports uterus during pregnancy

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Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and
true pelvis.

Nursing Care:

To prevent puerperal sepsis - < 48 hours only – vaginal pack

Bolus of Pitocin can lead to hypotension.

2. Third Stage: birth to expulsion of Placenta -placental stage

Placenta has 15 – 28 cotyledons
Placenta delivered from 3-10 minutes

Signs of placental separation

1. Fundus rises – becomes firm & globular “ Calkins sign”
2. Lengthening of the cord
3. Sudden gush of blood

Types of placental delivery

Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny
Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty

Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER

Hurrying of placental delivery will lead to inversion of uterus.

Nursing care for placenta:

 Check completeness of placenta.

 Check fundus (if relaxed, massage uterus)
 Check BP
 Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives”
 Monitor Hypertension (or give oxytocin IV)
 Check perineum for lacerations
 Assist MD for episioraphy
 Flat on bed

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  Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain
energy.

3. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage.
 Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.

Nursing Management:

 Placement of the fundus

o Palpate the fundus immediately after delivery, 2 hours it will be at the level of the umbilicus.
o If fundus above umbilicus, deviation of fundus

 Assist in emptying the bladder to prevent uterine atony.

 Check lochia
 Check the perineum for
R - edness
E- dema
E - cchymosis
D – ischarges
A – approximation of blood loss. Count pad & saturation

Fully soaked pad: 30 – 40 cc weigh pad. 1 gram=1cc

 Bonding – interaction between mother and newborn – rooming in types

 Straight rooming in baby: 24hrs with mom.
 Partial rooming in: baby in morning , at night nursery

E. Complications of Labor
Dystocia
 difficult labor related to:

Mechanical factor – due to uterine inertia – sluggishness of contraction

1.) hypertonic or primary uterine inertia

 intense excessive contractions resulting to ineffective pushing

 MD administer
sedative
valium,/diazepam
– muscle relaxant

2.) Hypotonic – secondary uterine

inertia- slow irregular
contraction resulting to
ineffective pushing. Give
oxytocin.

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Prolonged labor
 normal length of labor in primi 14 – 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
 Maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma
 Nursing Care: monitor contractions and FHR

Precipitate Labor

 Labor of < 3 hrs. Extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.

Earliest sign: tachycardia & restlessness

Late sign: hypotension
Outstanding Nursing Dx: fluid volume deficit
Post of mom – modified trendelenberg

IV – fast drip due fluid volume deficit

Signs of Hypovolemic Shock:

 Hypotension
 Tachycardia
 Tachypnea
 Cold clammy skin

Inversion of the uterus

 Situation uterus is inside out.

MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus

1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure

Uterine Rupture
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Causes:
1.) Previous classical CS
2.) Large baby
3.) Improper use of oxytocin (IV drip)

Signs & Symptoms

 sudden pain
 profuse bleeding
 hypovolemic shock

Management: Hysterectomy

Physiologic retraction ring

- Boundary bet upper/lower uterine segment

BANDL’S pathologic ring – suprapubic depression

a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism

 Amniotic fluid or fragments of placenta enters natural circulation resulting to embolism

Signs & Symptoms:

1. Dyspnea, chest pain & frothy sputum

Prepare: suctioning
End stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose,
etc.

Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 – 14, primi 14 – 20

Preterm Labor

(Labor after 20 – 37 weeks) (Abortion <20 weeks)

Signs & Symptoms:

1. Premature contractions q 10 min

2. Effacement of 60 – 80%
3. dilation 2-3 cm

Home Management:
1. Complete bed rest
2. Avoid sex
3. Empty bladder
4. Drink 3 -4 glasses of water – full bladder inhibits contractions
5. Consult MD if symptoms persist

Hosp:

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 1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
Antidote – propranolol or inderal - beta-blocker

If cervix is open – MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation

preventing RDS

Preterm - cut cord ASAP to prevent jaundice or hyperbilirubenia.

VI. Puerperium
A. Definitions:

Postpartal Period 5th stage of labor

 After 24hrs: Normal increase WBC up to 30,000 cumm

Puerperium – covers 1st 6 wks post partum

Involution – return of repro organ to its non pregnant state.

Hyperfibrinogenia

 Prone to thrombus formation

 Early ambulation

B. Principles underlying Puerperium

1. To return to Normal and facilitate healing (Involution)

a. Cardiovascular System/Vascular Changes

- the first few minutes after delivery is the most critical period in mothers because the increased in plasma
volume return to its normal state and thus adding to the workload of the heart. This is critical especially to
gravidocardiac mothers.

b. Genital Changes
 Cervix – cervical opening
 Vaginal and Pelvic Floor
 Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10th day – no longer
palpable due behind symphisis pubis
 3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a
medium for bacterial growth- (puerperal sepsis)- D&C
 After, birth pain:
1. Position prone
2. Cold compress – to prevent bleeding
3. mefenamic acid

Lochia - blood, wbc, deciduas, microorganism. NSD & CS Both have Lochia.
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 1. Rubra – red 1st 3 days present, musty/mousy, moderate amt
2. Serosa – pink to brown 4 – 9th day, limited amt
3. Alba – créme white 10 – 21 days very decreased amt

Dysuria
 urine collection
 alternate warm & cold compress
 stimulate bladder

Perineal area – painful – episiotomy site – sim’s position, cold compress for immediate pain after 24 hrs, hot
sitz bath, not compress

Sex- when perineum has healed

c. Urinary Changes: Bladder – freq in urination after delivery- urinary retention with overflow
d. Gastrointestinal Changes - Colon: Constipation – due NPO, fear of bearing down

2. Provide Emotional Support – Reva Rubia

Psychological Responses:

a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to
tell child birth experiences.

Nursing Care: - proper hygiene

b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions

Health Teaching:

1.) Care of newborn

2.) Insert family planting method
 common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming
feeling of depression characterized by crying, despondence- inability to sleep & lack of
appetite. – Let mom cry – therapeutic.

c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child
grows.

3. Prevent complications

I. Hemorrhage – bleeding of > 500cc

CS – 600 – 800 cc normal
NSD 500 cc

a. Early postpartum hemorrhage – bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding
- uterine atony.

Complications: hypovolemic shock.

Management:

1.) massage uterus until contracted

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 2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip

1st degree laceration – affects vaginal skin & mucus membrane.

2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum

Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
 assess perineum for laceration
 degree of laceration
 Management: Episiorraphy

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen - failure to coagulate.

 bleeding to any part of body

 hysterectomy if with abruption placenta
Management: BT- cryoprecipitate or fresh frozen plasma

b. Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments

Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta,
percreta,

Acreta – attached placenta to myometrium.

Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium

Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.

 too much manipulation

 large baby
 pudendal anesthesia

Management:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing

II. Infection - sources of infection

a. Sources

1.) Endogenous – from within body

2.) Exogenous – from outside
 Anaerobic streptococci – most common - from members health team
 unhealthy sexual practices

b. General signs of inflammation:

1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)

2. purulent discharges
3. fever

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 c. General Management:

 Supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity
– for antibiotic
o Prolonged use of antibiotic lead to fungal infection

Inflammation of perineum – see general signs of inflammation

Specific Symptoms:
2 to 3 stitches dislocated with purulent discharge

Management:

1. Removal of sutures & drainage, saline, between & resulting.

Endometriosis – inflammation of endometrial lining

Endometritis

Symptoms:
a. Abdominal tenderness
b. Uterus is not contracted and Painful to touch

Specific Management:

a. Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

VII. Family Planning

Motivate the use of Family Planning
1.) determine one’s own beliefs 1st
2.) never advice a permanent method of planning
3.) Method of choice is an individual’s choice.

Natural Method – the only method accepted by the Catholic Church

Billings / Cervical mucus – test spinnbarkeit & ferning (estrogen)

 clear, watery, stretchable, elastic – long spinnbarkeit

Basal Body Temperature - 13th day temp goes down before ovulation – no sex
 get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.

Breast feeding- menstruation will come out 4 – 6 months
Bottle fed 2 – 3 months
Disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method

1.) Coitus interuptus/ withdrawal - least effective method

 coitus reservatus – sex without ejaculation
 coitus interfemora – “ipit”
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  calendar method

OVULATION –count minus 14 days before next mens (14 days before next mens)

Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11

June 26 Dec 33
- 18 -11
8 - 22 unsafe days

21 day pill- start 5th day of menstruation

28day pill- start 1st day of menstruation
Missed 1 pill – take 2 next day

Physiologic Method

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Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of
FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to
become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

 In case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she
would wait for at least 3 months before attempting to conceive to provide time for the estrogen and
progesterone levels to return to normal.

 If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed
contraceptive and begin taking the new one on the first day of the next menses.
 Discontinue oral contraceptive if there is signs of severe headache as this is an indication of
hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

Signs of hypertension

Immediate Discontinuation

A – Abdominal pain
C – chest pain
H - headache
E – eye problems
S – Severe leg cramps
If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding

Contraindicated:
 chain smoker
 extreme obesity
 HPN
 DM
 Thrombophlebitis or problems in clotting factors

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  If forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If
forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the
start again.

DMPA – depoprovera – has progesterone inhibits LH – inhibits ovulation

 Depomedroxy progesterone acetate – IM q 3 months
 Never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.

 5 yrs – disadvantage if keloid skin

 as soon as removed – can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation – affects motility of sperm & ovum

 right time to insert is after delivery or during menstruation

Primary indication for use of IUD

 parity or # of children, if 1 kid only don’t use IUD

Health Teachings:
 Check for string daily
 Monthly checkup
 Regular pap smear

Alerts:
 prevents implantation
 most common complications: excessive menstrual flow and expulsion of the device (common problem)
 Others:

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 P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy

Condom – latex inserted to erected penis or lubricated vagina

Adv; gives highest protection against STD – female condom

83
Alerts:
Disadvantage:
 it lessen sexual satisfaction
 it gives higher protection in the prevention of STDs

Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus.

REVERSABLE

Health Teachings:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 – 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome

Alerts: Should be kept in place for about 6 – 8 hours

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Cervical Cap – most durable than diaphragm no need to apply spermicide
C/I: abnormal Pap smear

Foams, Jellies, Creams

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Surgical Method – BTL, Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects

Vasectomy – cut vas deferens.

HT: >30 ejaculations before safe sex

O – Zero sperm count, safe

VIII. High Risk Pregnancy

I. Hemorrhagic Disorders
General Management:

1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not

First Trimester Bleeding – abortion or ectopic

A. Abortions – termination of pregnancy before age of viability (before 20 weeks)

Spontaneous Abortion- miscarriage

Cause:
1.) Chromosomal alterations
2.) Blighted ovum
3.) Plasma germ defect

Classifications:
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 a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete – all products of conception are expelled. No mgt just emotional support!
2.) Incomplete – Placental and membranes retained. Mgt: D&C
Incompetent cervix – abortion
McDonald’s procedure – temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan – permanent surgery cervix. CS

c. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
Present 2nd trimester
d. Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy
cease. (-) preg test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser
evil.

C. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity.

Common site: tubal or ampullar

Dangerous site – interstitial

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Unruptured Tubal rupture
 missed period  Sudden, sharp, severe pain. Unilateral
 abdominal pain within 3 -5 weeks of missed radiating to shoulder.
period (maybe generalized or one sided) shoulder pain (indicative of intraperitoneal bleeding
 scant, dark brown, vaginal bleeding that extends to diaphragm and phrenic nerve)
+ Cullen’s Sign – bluish tinged umbilicus – signifies
Nursing care: intra peritoneal bleeding
syncope (fainting)
Vital signs Mgt:
Administer IV fluids Surgery depending on side
Monitor for vaginal bleeding Ovary: oophrectomy
Monitor I & O Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization.

Progressive degeneration of chorionic villi. Recurs.

Gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the
selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing
a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Use: methotrexate to prevent choriocarcinoma

Assessment:

Early signs
 vesicles passed thru the vagina
 Hyperemesis gravidarium increase HCG
 Fundal height
 Vaginal bleeding( scant or profuse)

Early in pregnancy
 High levels of HCG
 Preeclampsia at about 12 weeks

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Late signs
 hypertension before 20th week
 Vesicles look like a “ snowstorm” on sonogram
 Anemia
 Abdominal cramping

Serious complications
 Hyperthyroidism
 Pulmonary embolus

Nursing care:
 Prepare D&C
 Do not give oxytoxic drugs

Teachings:

a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus
and rising titer could indicative of choriocarcinoma
b. Avoid pregnancy for at least one year

Third Trimester Bleeding “Placenta Anomalies”

D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment,
sometimes covering the cervical os. Abnormal lower implantation of placenta.
 candidate for CS

Signs & Symptoms:

 Frank Bright red bleeding
 Painless bleeding

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 Dx:
 Ultrasound
 Avoid: sex, IE, enema – may lead to sudden fetal blood loss
 Double set up: delivery room may be converted to OR

Assessment:
 Engagement (usually has not occurred)
 Fetal distress
 Presentation (usually abnormal)

Surgeon – in charge of sign consent, RN as witness

- MD explain to patient
Complication: sudden fetal blood loss

Nursing Care
 NPO
 Bed rest
 Prepare to induce labor if cervix is ripe
 Administer IV

E. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually
occurs after the twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:
 Concealed bleeding (retroplacental)
 Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to
hemorrhage.
 Severe abdominal pain
 Dropping coagulation factor (a potential for DIC)

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Complications:
 Sudden fetal blood loss
 placenta previa & vasa previa

Nursing Care:
 Infuse IV, prepare to administer blood
 Type and crossmatch
 Monitor FHR
 Insert Foley
 Measure blood loss; count pads
 Report s/sx of DIC
 Monitor v/s for shock
 Strict I&O

F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to
retained placental fragments if vessel is cut.

G. Placenta Circumvalata – fetal side of placenta covered by chorion

H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta

I. Battledore Placenta – cord inserted marginally rather then centrally

J. Placenta Bipartita – placenta divides into 2 lobes

K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta

L. Vasa Previa – velamentous insertion of cord has implanted in cervical OS

II. Hypertensive Disorders

A. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.) Gestational hypertension - HPN without edema & protenuria H without EP

2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

B. Transissional Hypertension – HPN between 20 – 24 weeks

C. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.

Three types of pre-eclampsia

1.) Mild preeclampsia – earliest sign of preeclampsia

a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2

2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually
indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.

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Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to
urinate.

P- Prevent convulsions by nursing measures or seizure precaution

1.) Dimly lit room. Quiet calm environment
2.) Minimal handling – planning procedure
3.) Avoid jarring bed

P- Prepare the following at bedside

 Tongue depressor
 turning to side done AFTER seizure! Observe only! for safely.
E – Ensure high protein intake ( 1g/kg/day)
 Na – in moderation

A – Anti-hypertensive drug Hydralazine ( Apresoline)

C – Convulsion, prevent – Mg So4 – CNS depressant
E – Valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent – 1st sigh Mg SO4 toxicity. antidote – Ca gluconate

D. Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)

Function: of insulin – facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose – 80 – 120 mg/dl < 80 – hypoclycemic
( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL

Maternal effect DM
1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic
2.) Frequent infection- moniliasis
3.) Polyhydramnios
4.) Dystocia-difficult birth due to abnormalities in fetus or mom.
5.) Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd
trimester.
Post partum decrease 25% due placenta out.

Fetal effect:

1.) Hyper & hypoglycemia

2.) Macrosomia – large gestational age – baby delivered > 400g or 4kg
3.) Preterm birth to prevent stillbirth

Newborn Effect: DM

1.) hyperinsulinism
2.) hypoglycemia

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 normal glucose in newborn 45 – 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test – get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose

3.) hypocalcemia - < 7mg%

Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium

Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta

Class I & II- good progress for vaginal delivery

Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

Heart disease

Moms with RHD at childhood

Class I – no limit to physical activity
Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II

1.) sleep 10 hrs a day
2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) Early hospitalization by 7 months

Class IV. Marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion

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 VIII. Intrapartal Complications
1. Cesarean Delivery Indications:

a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
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 h. CPD primary indication
i. Breech presentation
j. Transverse lie

Procedure:

a. Classical – vertical insertion. Once classical always classical

b. Low segment – bikini line type – aesthetic use

VBAC – vaginal birth after CS

DISORDERS OF SEXUAL FUNCTIONING

A. PRIMARY SEXUAL DYSFUNCTION

1. Frigidity – lack of pleasure in intercourse.
2. Dyspareunia – painful intercourse.

 Causes :
a. psychosomatic – anxiety
b. social and economic difficulties
c. local lesion, rigid hymen

 Frigidity and dyspareunia are indicative of :

a. marital difficulties arising from :
- ignorance - emotional immaturity
- misinformation - insecurities
- anxiety, fear
b. social and economic insecurities

3. Impotence / erectile dysfunction – inability to achieve a sustained erection sufficient to allow vaginal penetration.

 Causes :
a. drugs and alcohol
b. psychologic – stress, depression
c. congenital

 Mgt:
a. depends on the causes
b. sexual counseling

4. Premature ejaculation – ejaculation before penile – vaginal contact. It can cause unsatisfactory for both partners.

 Causes :
a. psychologic
b. masturbating to orgasm
c. doubt about masculinity
d. fear of impregnating

 Mgt :
 sexual counseling

5. Female orgasmic dysfunction – woman who does not attain orgasm during their entire life span.

 Includes the following :

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 5.1 Coital orgasmic inadequacy – woman who is only capable of having an orgasm with partner manipulation, oral
– genital stimulation or masturbation.
5.2 Masturbatory orgasmic dysfunction – woman who can be orgasmic during intercourse but with no other kind of
stimulation.

 Factors :
a. religious prohibition
b. being raised in a protective environment that excluded acknowledgement of sexual feeling or behavior.
c. Inability to identify with one’s inadequate partner
d. Marriage with inadequate man

6. Vaginismus - involuntary contraction of the muscles at the outlet of vagina when coitus is attempted. It may occur in
woman who has been raped.

 Dx:
Pelvic exam.

 Factors :
a. married to impotent men
b. family background reflect the attitude that sex was considered “ dirty or sinful “

7. Inhibited sexual desire - lack of desire for sexual relation.

 Predisposing factors :
a. death of family member
b. divorce
c. stressful job

B. INFERTILITY AND STERILITY

Infertility – when pregnancy has not occurred after at least one year of effort.
Sterility – inability to produce offspring.

 Types of infertility :
a. Primary infertility – there have been no previous conception.
b. Secondary infertility – there have been a previous viable pregnancy but unsuccessful .
c. Idiopathic infertility – no definite cause for the infertility can be found.

 Components of fertility :
1. The husband must produce sperm of adequate quantity and quality.
2. The sperm must gain entry not only into the vagina but into the womb itself during the wife’s fertile period.
3. The wife must ovulate.
4. The egg must be of good quality.
5. The wife’s tube must be open to received the egg each month and to permit the entry of sperm.
6. The tubes and womb must not be obstructed to permit a fertilized egg free passageway into the uterus and it
should also have a lining favorable for the implantation.
7. The various glands concerned with reproduction must be working harmoniously.

 Causes of infertility :

A. Male
1. Inadequate sperm count
Azoospermia - absence of sperm
Oligospermia
 Factors contributing to infertility :
1. Genetic or developmental factors
a. production of deformed sperm
b. abnormalities of testicle
c. epispadias or hypospadias
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 d. chromosomal trisomy ( xxy )
2. Hormonal factors
3. Mechanical obstructions
a. retrograde ejaculation
b. spinal cord injury or disease
c. adhesion from previous surgery
d. salphingitis
e. endometriosis
f. repair of ectopic pregnancy
4. Chemical or environmental factors
a. drug abuse
b. alcoholism
c. excessive hot tub use
d. strenuous exercises
e. obesity or extreme underweight
5. Inflammatory process and immunologic factors
a. gonorrhea
b. prostatitis
c. epididymitis
d. post abortion sepsis

6. Psychogenic factors
a. physical or mental stress
b. poor information regarding sexual technique
c. anorexia nervosa

7. Chronic illness or deficiency

a. severe diabetes
b. thyroid disease
c. renal disease
d. cardiac disease
e. anemia

 Causes of Infertility :

A. Male
1. Inadequate sperm count
Azoospermia – absence of sperm
Oligospermia – decrease sperm count
Asthenospermia – decrease motility
Teratospermia – low percentage, abnormal morphology

 Causes :
1.1. chronic disease such as PTB or recurrent sinusitis because of slightly elevated temperature, there is a
decrease in spermatozoa
1.2. orchitis that follows mumps
1.3. exposure to excessive x – rays or radioactive substance
1.4. excessive use of alcohol or drugs ( alcohol causes erectile problem )
1.5. low vitamin intake
1.6. surgery near the testes
1.7. presence of varicocele ( varicosity of the spermatic vein )
1.8. Heavy use of marijuana, alcohol or cocaine with 2 years of testing – can depress sperm count and
testosterone level.
1.9. Cigarette smoking may depress sperm motility
2. Obstruction of sperm motility may occur at any point in the pathway that spermatozoa must travel to reach the
outside.
3. Changes in seminal fluid – infection of the prostate gland through which seminal fluid passes or infection of the
seminal vesicles change the composition of seminal fluid to reduce sperm motility.
4. Dificulty with ejaculation – too frequent intercourse may reduce sperm count. Abnormalities of the penis such
as hypospadias ( urethral opening in the ventral surface of the penis ) or epispadias ( opening in the dorsal

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 surface may cause deposition of spermatozoa too far from the cervix to allow for cervical penetration.)
Psychological problems and premature ejaculation may affect the proper deposition of sperm.

 Assessment :
a. history taking - ask the client on :
 congenital problem
 coital position used
 contraceptive method used
 occupation and work habit
 frequency of intercourse and masturbation
 ever fathered by a previous marriage or relationship
b.physical assessment – observation of secondary sexual characteristics and genital abnormalities.

 Test and examination :

I. Semen analysis - provides information about sperm.
 Normal semen analysis value :
Liquefaction – usually complete within 10 – 3- mins.
Semen volume – 2 – 5 ml.
Semen pH - 7.2 – 7.8
Color – opaque
Sperm density – 20 – 200 million/ml
Normal morphology ( % ) - > 60% normal oval
Motility – 60 % of sperm should be motile
Cell count : average normal – 60 million/ml or a total of 150 – 200 or more million/ejaculate
Minimum normal standard – 40 million/ml with total count of at least 125 million/ejaculate

Semen is collected after 2 – 3 days of abstinence and usually by masturbation to avoid contamination or loss of
any ejaculate and brought to the lab. In a sealed container within of ejaculation. Exposure to excessive heat or cold is
avoided. Repeated semen analysis maybe required to assess the male’s fertility potential adequately. Because of the
cycle of spermatogenesis is 72 days, semen collection should be repeated at least 74 days apart to allow for new sperm
maturation.

II. Routine urine test, CBC, serologic test for syphilis

III. Post coital test – for adequacy of coital technique, cervical mucus, sperm and degree of sperm penetration through
cervical mucus. It is performed within 2 hours after ejaculation of semen into the vagina and performed only in the
absence of vaginal infection.

 Therapy :
1. Drug therapy - testosterone enanthate ( Delatestryl ) and testosterone cypionate ( Depo – testosterone ) by
injection - to stimulate virilization.
 hCG ( Pregnyl ) – to restore leydig cell function and spermatogenesis.
 FSH and hMG – aid hCG for completion of spermatogenesis.

2. Surgical repair of varicocele

3. Simple changes in life - style

B. Female
1. Anovulation -
 Causes :
a. pituitary or thyroid disturbance
b. immaturity or disease of the ovaries
c. excessive wt. Gain
d. excessive exercise
e. extreme emotional stress
f. excessive hair growth, acne, oily skin

 Test :
1.1 Basal body temperature - aid in identifying follicular, ovulatory and luteal phase abnormalities. It should be taken
every morning before getting out of bed . ( after at least 3 hours of sleep ) Basal temperature in the preovulatory
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 phase is usually below 36.7 C ( 98 F ) . As ovulation approaches, production of estrogen increase and at its may
cause a slight drop, then rise, in the basal temperature. When ovulation occurs, there is s surge of LH and
progesterone is produced by the corpus luteum causing 0.3 C to 0.6 C ( 0.5 F to 1.0 F ) increase in basal
temperature.

1.2 Fern test – usually done at midcycle and again before midcycle and again before menstruation. When high level of
estrogen are present in the body, as they are just prior to ovulation, the cervical mucus forms fern like patterns
when it is smeared and dried in a glass slide. When progesterone is the dominant hormone, a fern pattern is no
longer discernible.

1.3 Spinnbarkeit test or mucus elasticity – at the height of estrogen secretion, the cervical mucus becomes thin and
watery and can be stretched and when progesterone is the dominant hormone, it is contrast to its state.

1.4 Uterine endometrial biopsy – provides information about ovulation by assessing the adequacy of corpus luteum
function and endometrial receptivity. A corkscrew like appearance of the endometrium suggest ovulation has
occurred. It is done by introducing a thin probe and biopsy forcep through the cervix. It is usually done during the
24th – 26th day of a typical menstrual cycle and contraindicated if pregnancy and infection is suspected.

1.5 Culdoscopy – a sterile procedure performed to permit visualization of the organ of reproduction through a
culdoscope inserted into the posterior fornix of the vaginal canal. Both ovaries can be inspected grossly for the
presence of a graafian follicle, corpus luteum or corpus albicans.

1.6. Ultrasound ( transvaginal ) – method of choice for follicular monitoring.

2. Tubal factors
 Causes :
a. chronic pelvic inflammatory disease
b. rupture appendix or abdominal surgery
c. congenital webbing or strictures of the fallopian tube

 Test :
1.1. Rubin test - done in the 3rd day following cessation of menstrual flow, before the ovum has entered the fallopian
tube. Carbon dioxide is instilled into the cervix under pressure. It passes through the uterus and fallopian tube into
the pelvic cavity if the tubes are patent. After few hours, as the carbon dioxide is diffused into the peritoneum and
collects under the diaphragm, the woman experience sharp pain one or both shoulders. This is normal. It is
contraindicated when uterine bleeding or infection is present.

1.2. Hysterosalpingography (HSG) or Hysterogram – involves an instillation of a radiopaque substance into the uterine
cavity. As the substance fills the uterus and fallopian tube and spills into the peritoneal cavity, it is viewed with x –
ray technique. It should be performed in the proliferative phase of the cycle to avoid interrupting an early
pregnancy. It causes moderate discomfort and serious recurrence of PID.

1.3. Hysteroscopy – allow further evaluation on any areas of suspicion within the uterine cavity revealed by HSG.

1.4. Laparoscopy – direct visualization of the pelvic organs and is usually done 6 – 8 mos. After HSG unless symptoms
suggest the need for earlier evaluation.

3. Uterine factors
 Causes :
a. tumors
b. congenital deformed uterine cavity
c. Inadequate endometrium formation resulting from poor secretion of estrogen and progesterone.
d. previous D and C
e. induced abortion
f. recurrent abortion
g. menorrhagia

 Test :
 same with tubal test

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4. Cervical factors - wherein the sperm is in hostile environment or cannot penetrate the cervix to pass into the
uterus.
 Causes :
a. infection of the cervix
b. tight cervical OS
c. previous cervical surgery
d. postpartum D and C
e. douching

 Test:
4.1. Sims – Huhner test – help to assess abnormalities in cervical mucus and sperm motility. The basal body
temperature is taken and during ovulation, the couple should have intercourse. After intercourse, woman lies on
her back for at least 30 mins. To ensure that spermatozoa will reach the cervix.

4.2 Fern test

4.3. Spinnbarkeit test

5. Vaginal factors
 Causes :
a. infection
b. blood incompatibility

 Test :
5.1. Pelvic examination

5.2. Vaginal secretion culture

6. Pelvic factors
 Causes :
a. history of appendectomy, abdominal surgery
b. PID
c. IUD insertion
d. Premenstrual bleeding, dysmenorrhea, dyspareunea

 Assessment :
1. History taking - ask the client on :
 menstrual history including age of menarche, length and frequency of menstrual period, amount of
flow
 present or past infection
 over all health
 abdominal or pelvic operation
 previous pregnancy or abortion
 family planning device used

 occupational hazard
2. Physical assessment
3. Laboratory test - urinalysis
 CBC
 Serologic test

 Methods of Infertility Management :

I Drug therapy
1. Clomiphene citrate ( Clomid, Serophene )
Action: stimulates follicular growth by increasing secretion of FSH and LH
Route, dosage, frequency: administered orally 50 mg/day – 250 mg/day from day 5 – day 9 ( total of 5 days )
of menstrual cycle
Contraindication: presence of ovarian enlargement, ovarian cyst, pregnancy
S/E : - abnormal uterine bleeding
 increase risk of multiple pregnancy

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  bloating
 breast discomfort

2. Human menopausal gonadotropin ( hMG )

 also referred to Pergonal ( Menotropin ) a mixture of FSH and LH; and Metrodin ( Urofollitropin ) a
FSH only
 Indicated as a first line of therapy for the anovulatory infertile woman with low to normal level of
gonadotropin (FSH and LH) and as a second line of therapy who fail to ovulate or conceive with
Clomid therapy.

3. Parlodel – act directly on the prolactin secreting cells in the anterior pituitary. It inhibit the pituitary’s secretion of
FSH and LH. This restores normal menstrual cycles and induces ovulation by allowing FSH and LH production.

4. Danazol ( Danocrine ) – maybe given to suppress ovulation and menstruation and to effect atrophy of the ectopic
endometrial tissue.

5. Gonadotropin- releasing hormone ( GnRH ) – a therapeutic tool for ovulation stimulation. It is used for women
who have insufficient endogenous release of GnRH. The length of treatment varies from 2 – 4 wks. and HCG is
also given to stimulate ovulation.

OPERATIVE OBSTETRICS
A. FORCEP DELIVERY
 Obstetric forcep is an instrument designed to deliver the head of the fetus .

 Parts of forcep:

1. Blades (fenestrated or solid)

2. Shank (long or short)
3. Lock (sliding, fixed screw )
4. Handle

 CATEGORIES OF FORCEP APPLICATION:

1. Outlet forcep
2. Low forcep
3. Midforcep

CRITERIA FOR OUTLET FORCEP APPLICATION:

1. Forceps are applied when the fetal skull has reached the perineum.
2. The scalp is visible between contraction.
3. Sagittal suture is not >15 degrees from the midline.

CRITERIA FOR LOW FORCEP:

 Presenting part is at the station +2 or more.

CRITERIA FOR MIDFORCEP:

 Fetal head is engaged.

INDICATION FOR USE OF FORCEP:

1. heart dse
2. exhaustion

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2. acute pulmonary edema
3. intrapartum infxn
4. rigid pelvic floor
5. it may also be used “electively” to shorten the 2 nd stage of labor.

NURSING CARE:
1. Explain the procedure.
2. Encourage pt. To maintain breathing tech.
3. Monitor contraction and FHR

DANGERS OF FORCEP DELIVERY:

 to the mother :
a. extensive laceration
b. hemorrhage
c. infxn

 to the baby :
a. intracranial injuries
b. disfigurement

B. VACUUM EXTRACTOR
 Instrument designed to facilitate the delivery of the fetal head by using suction ,applied to the fetal head and the
traction gained with the uterine contraction.

 INDICATION : prolonged 2nd stage

 CONTRAINDICATION:

1. face or breech pres.

2. Extreme prematurity
3. Macrosomia
4. Previous fetal scalp bld sampling

C. CAESARIAN OPERATION
 Defined as delivery of the fetus through incision in the abdominal wall and uterine wall.

 SURGICAL TECH.

A. SKIN INCISION
1. Transverse ( pfannensteil )- made across the lowest and narrowest part of the abdomen.
 bec. The incision is made just below the pubic hair line, it is almost invisible after healing.

2. Vertical ( infraumbilical /midline ) – made between the navel and symphysis pubis.
 Incision is quicker and preferred in cases of fetal distress.

 The type of skin incision is determined by time factor, client pref. Or physician pref.

B. UTERINE INCISION
1. lower uterine segment incision - most commonly used is a transverse incision although a vertical
incision may also be used.

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  Transverse incision is preferred for the ff. reason :
1.a. lower segment is the thinnest portion of the uterus and
involve less bld loss.
1.b. requires only mod. dissection of bladder from underlying
myometrium.
1.c. easier to repair, although repair takes longer .
1.d. site is less likely to rupture during subsequent preg.
1.e. decrease chance of adherence of bowel or mentum to
incision line.

 Disadvantage:
1.a. takes longer to make transverse incision.
1.b. limited in size bec. of the (+) of major bld vessels on
either side of uterus.
1.c. greater tendency to extend laterally into uterine vessel.

 vertical incision :
 preferred for multiple gestation, abnormal pres., placenta previa. Fetal distress and preterm and
macrosomic fetus.

 Disadvantages:
1.incision may extend downward into cervix.
2.More extensive dissection of the bladder is needed.

2. Classic incision/ upper uterine segment

 more blood loss resulted.
 More difficult to repair
 Increase risk of uterine rupture with subsequent preg., labor and birth.

 INDICATION:
1. placenta previa
2. abruptio placenta
3. breech pres.
4. CPD
5. Active genital herpes
6. Umbilical cord prolapse
7. Failure to progress in labor

INFLAMMATORY DISTURBANCE
A. MALE
1. Orchitis - inflammation of the testes. Results from complication of mumps. If occur after puberty, it may lead to
sterility.

 S/Sx:
a. Pain in the scrotal sac
b. Nausea and vomiting
c. Chills

 Tx:
a. Bed rest
b. Hot and cold application
c. Scrotal support
d. Gamma globulin

2. Epididymitis - infection from urine, urethra, prostate gland and seminal vesicles.
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  S/Sx:
a. Difficulty in walking
b. Severe pain
c. Dysuria

 Causes: organism as streptococci, gonococci

 Tx:
a. Antibiotic
b. Bed rest
b. Scrotum should be elevated with cold towel – to relieved pain

3. Prostatitis - sequela of urethritis, ascending infection.

 S/Sx:
a. Enlarged prostate
b. Inflammation of inguinal area and scrotal area

 Tx:
a. Antibiotic
b. Rectal irrigation of warm saline soln

4. Urethritis - inflammation of urethra

 S/Sx: inguinal pain

 Tx:
a. Systemic antibiotic
b. Oral fluid

B. FEMALE

I. DISEASES OF THE VAGINA

1. Simple vaginitis - infectious organism like E. coli, staphylococci and streptococci change the normal acidity of
vagina.
 Doderlein bacillus is the main line of defense in the vagina which needs a pH of 3.5 - 4.5
 A result of poor hygiene

 S/Sx :
a. Presence of leukorrhea – primary symptom. During pre and postmenstrual days, the flow is often
milky and may appear as small, white clumps of “material”.
b. vulvar irritation
c. Burning, pruritus esp. after urination
d. Redness
e. Edema of surrounding tissues

 Tx:
a. Douching with tbsp. Of vinegar to 1 qt. water or
lactacyd
b. To restore normal acidity.
c. Hot sitz – to decrease inflammation
d. Topical cream – may relieve discomfort
e. Antibiotics – to eradicate the microorganism

2. Trichomonas vaginitis – initial source is unknown

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  S/Sx:
a. Presence of thin, gray or yellowish – greenish frothy foamy or bubbly discharge.
b. Vulva is usually irritated, edematous
c. Pruritus
d. Urinary frequency
e. Dysuria
f. Lower abdominal pain
g. dyspareunia

 Tx:
- use of Flagyl IV or vaginally 500 mg BID for 5 days
S/E: GI disturbance
S/P: not to be used during the first trimester

 Nursing Intervention:
a. Sexual abstinence
b. Douche
c. Sunshine, rest and good nutrition
d. tampoon - to absorb discharge
e. Good perineal hygiene

3. Mycotic vaginitis /Monilial vaginitis - caused by candida albicans and fungus.

 S/Sx :

a. Presence of thick, cheesy vaginal discharge

b. pruritus
c. Local irritation
d. Marked reddening of the entire vulvovaginal mucous membrane

 Tx:

a. Use of Gentian violet or Mycostatin or Monistat – 3 mos.

b. Mycolog cream – to reduce vulvar irritation and itching.

4. Haemophilus vaginitis – caused by haemophilus vaginalis

 S/Sx:
a. Offensive discharge with little or no discomfort or itching
b. Local evidence of infection in the epithelium
c. Very slight creamy discharge

 Tx:
a. Local therapy with Sulfonamides
b. Sulfa cream –at least 3 – 4 wks.
c. Terramycin supp.
d. Ampicillin 500 mg. q 6 hrs. x 5 days

5. Senile/ Postmenopausal vaginitis – result from atrophy of the vaginal mucosa.

 S/Sx:
a. Thin, blood – tinged discharge
b. dyspareunia

 Tx:
a. Estrogen therapy
b. Vaginal suppositories or cream (Stilbestrol 0.5 mg) 2
– 3 x a wk.
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6. Bacterial vaginosis/non – specific vaginitis - the most common cause of vaginal symptoms among childbearing
women caused by Gardnerella vaginalis.

 Clinical signs:
a. Vaginal fluid pH is elevated
b. Amine (fishy) odor when mixed with 10% KCL
c. Milk like discharge
d. Itching, burning sensation
e. Pain maybe present in the vagina

 Predisposing factors:
a. Amniotic fluid infection
b. PROM
c. Preterm labor and delivery
d. Post partum endometritis
e. PID

 Tx:
a. Oral Metronidazole – should be given in the 2nd and 3rd trimester
b. Topical prep. Of Metronidazole and Clindamycin

II. DISEASES OF CERVIX

1. Acute cervicitis – inflammation of the cervix uteri caused by bacterial, viral, protozoal and fungal. This follows
laceration after birth. The cervix is reddened, congested and somewhat swollen while there is a profuse, purelent exudate
sometimes white or yellowish.

 S/Sx:
a. Backache
b. leukorrhoea
c. Irregular mens

 Dx:
a. Speculum exam. of the cervix
b. cytologic smear – to R/O CA
c. Biopsy

 Tx:
a. Cauterization
b. Vaginal suppositories
c. Antibiotic

2. Chronic cervicitis

 S/Sx:
a. Persistent leukorrhea
b. Thick, viscid discharge
c. Abdominal discomfort
d. dyspareunia
e. Spotting of blood between period and / after intercourse

 Tx:
a. cryotherapy – destruction of cervical epithelium by freezing
b. Cauterization – complete healing requires 7 – 8 wks.
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3. Cervical polyp - usually small tumors arising from the cervical canal extending downward toward or through the
cervical os. Generally, benign and maybe single or multiple characterized by bright red growths.

 S/Sx:
- Bleeding after coitus or may cause slight bleeding after defecation

 Dx:
a. Pap smear
b. Inspection of polyp
c. Biopsy of cervix and endometrium if bleeding persist

 Tx: removal of polyp

4. Ectoplasia or erosion - deep red appearance on the face of the cervix resulting from trauma or infection.

 Tx:
a. electrocautery
b. Use of vinegar ( acid ) douches
5. Laceration - deep extensive laceration either bilateral or stellate.

 Tx: require surgery

6. Cervical stenosis - may occur after laceration, cone biopsy, cryotherapy or cervical cauterization, and in cervical CA
during radiation therapy. If due to atrophy, it is not symtomatic. If malignancy occur, blood or mucus may fill the cavity and
cause pain and cramping.

 S/Sx::
 dysmenorrhea

 Tx: drainage

III. DISEASES OF THE VULVA

A. Inflammatory diseases:

 The vulvar skin maybe the site of any and all of the common dermatologic diseases caused of local irritants like
vaginal discharges, menstrual fluids, urine, feces and secretion from skene gland.

1. Intertrigo – common in the inner labial and crucal folds.

 Clinical signs:
a. Skin is erythematous ( initial phase )
b. Linear fissuring
c. Thickening and cracking skin

 Tx:
a. Drying powders
b. Elimination of tight undergarments

2. Seborrhea and seborrheic dermatitis - excessive secretion of the sebacious glands into both labial folds produces
an irritation and later, demonstrate crushing and scaling of the skin.

B. Diseases of the vestibular glands

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1. Batholin adenitis - the gland becomes swollen and painful with purelent exudate.

 Tx:
a. Bed rest
b. Analgesic – to relieve pain
c. Local thermotherapy ( ice pack or hot sitz )
d. Antibacterial therapy
e. I and D - if abcess formation is noted

2. Sebaceous or inclusion cysts - results from inflammatory blockage of the ducts of sebaceous glands and are usually
small, most commonly on the inner surfaces of the labia majora and minora.

 They contain a cheesy sebaceous material with formation of small furuncle like abscess.

 Tx:
 if it is small and asymptomatic – no treatment required
if it is large and annoying – excision is required

IV. DISEASES OF THE UTERUS

1. Myoma - muscle tumor, which composed chiefly of, unstripped muscled fibrous connective tissue.
Often called fibroids
They occur single or multiple
Cause is unknown
Location maybe cervical or corporal

 S/Sx :
1.hypermenorrhea – due to excessive estrogen effect
2. Bearing down sensation
3. Pressure symptoms
4. Pelvic pain
5. Bladder disturbance
6. Presence of mass upon palpation

 TX: surgical intervention

V. DISEASES OF THE OVARY

1. Simple cysts

a. Follicular cysts - varies from a small, pea sized structure to a size of an egg. It may be unilateral or
bilateral. It contains a clear, serous fluid. It represent an altered graafian follicle

b. Corpus luteum cysts – lined with slightly yellowish epithelium and filled with a pale yellowish – stained
clear fluid. It is usually unilateral.

c. Cystic teratomas - contain one or all-primary germ cell layers.

2. Dermoid cysts – there is filled with sebaceous material elaborated by the skin – like lining. It contains abundant hair,
cartilage, bone, teeth, brain cells and other tissues. It can be unilateral or bilateral and usually seen in young women.

VI. PELVIC INFLAMMATORY DISEASE (PID)

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  these involve the uterus, fallopian tubes, ovaries, peritoneum or any extension from these organs.

Etiology:
a. Gonorrheal – due to infection by Neisseria gonorrheae
b. pyogenic - due to infection by a large variety of organism like E. coli and streptococci

 S/Sx :
a. Severe pain in the pelvis and lower abdominal region
b. Muscular rigidity and tenderness
c. Abdominal distention
d. Nausea and vomiting
e. Fever
f. Rapid pulse

 Tx :
a. Bed rest e. avoid sexual relation
b. Adequate IVF f. Hot compress at lower back
c. Analgesic g. sitz bath
d. Antibiotic

VII. ENDOMETRIOSIS
 A condition characterized by presence of endometrial tissue outside the endometrial cavity. This occurs at
any age after puberty.

 Common sites affected:

a. Ovaries f. uterosacral ligament
b. Cul-de-sac of Douglas g. pelvic peritoneum
c. rectovaginal septum
d. Sigmoid colon
e. Round ligament

 Symptoms:
a. dysmenorrhea
b. Pain on defication during the time of menstrual cycle
c. Pelvic heaviness
d. dyspareunia
e. Abnormal uterine bleeding

 Dx:
a. laparoscopy - exam. of the interior of the abdomen
by inserting a small telescope through anterior abdl. Wall.
b. laparotomy
c. Bimanual exam.- may reveal a fixed, tender, retroverted uterus and
Palpable nodules.

 Tx:
a. Depends on the severity of symptoms:
b. Mild - require analgesic
c. Severe – treated with low estrogen to progestin ratio oral
d. Contraceptive - to shrink endometrial tissue
 Danazol – a mildly synthetic androgenic steroid that suppress FSH and LH secretion
 S/E:
a. masculinizing traits in woman
b. Weight gain
c. Decrease breast size
d. Edema
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 e. Migraine headaches
f. Decrease libido
g. Dizziness
 a. Not in used in pregnant woman – can produce pseudohermaphroditism in female
fetus
b. Contraindicated with liver disease
c. Should used in caution with cardiac and
renal disease

VIII. SEXUALLY TRANSMITTED DISEASES

1. Chlamidial infection – the most common sexually transmitted bacterial pathogen caused by chlamydia trachomatis.
The transmission occurs by direct contact (sexual contact).

 S/Sx :
a. Often asymptomatic
b. Thin or purelent discharge
c. Burning and frequency of urination
d. dyspareunia
e. Lower abdominal pain

 Fetal / Neonatal effect :

a. Stillbirth and neonatal death
b. ophthalmia neonatorum
(TX: erythromycin ophthalmic ointment)
c. Pneumonia

 Dx: tissue culture

 Tx :
a. Non pregnancy: doxycycline or tetracycline
b. Pregnancy: erythromycin or amoxycillin

2. Gonorrhea - caused by Neisseria gonorrheae spread by direct contact and indirect contact through inanimate object
or fomites. (Secretion on fomites such as washcloths, towels, blood linens and clothing often are implicated)

 Incubation period: 2 – 5 days

 S/Sx :
a. dysuria and urinary frequency
b. Heavy green – yellow purelent discharge
c. Cervical tenderness
d. dyspareunia
e. Post – coital bleeding
f. Lower abdominal pain
g. In some cases, swollen and inflammation of the vulva
Occur

 Tx:

a. For non-pregnancy and pregnancy: antibiotic therapy such as cefriaxone 250 mg IM OD + doxycycline 100
mg PO BID x 7 days. If allergy with cefriaxone, spectinomycin is given followed by doxycycline
b. Sexual partners should be treated

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  Neonatal effect:
a. Ophthalmia neonatorum
b. Pneumonia

3. Syphilis – caused by treponema pallidum. It can be acquired congenitally through transplacental inoculation (16th – 18
wks of gestation).

 Incubation period : 10 – 90 days

 S/Sx :

a. Early / primary stage

1.painless chancre appears at the organism site -
perineum,labia, cervix, anus, mouth and lips.
(Chancre appears 4 – 6 wks. Then disappear)
2. Slight fever
3. Loss of weight
4. Malaise

b. Secondary stage – occur 6 wks. – 6 mos.

1. Skin eruption secondary to non-tender rash may appear anywhere over the body including palms and
hands and soles of feet.
2. If rashes develop on the scalp, alopecia is noticed
3. Malaise
4. Anorexia
5. Fever
6. Headache

c. Tertiary stage- Clinical evidence of disease throughout the body especially bones, cardiac and
neurologic.

 Fetal / neonatal effect:

 Primary and secondary stages of untreated syphilis lead
to stillbirth, preterm birth and neonatal death.

 Dx :
a. Dark field exam.
b. Blood test such as VDRL (venereal disease
Research lab)

 Tx: penicillin

4. Herpes simplex virus (HSV) type 2 - is usually associated with genital infection and can occur as oral lesion after oral
genital sexual contact.

 Incubation period: 2 – 4 wks.

- Primary infection involves mucotaneous cells

- Recurrent infection involves stratified epithelial cells

 S/Sx:
A. Primary:
1. Multiple blister like vesicle usually in the genital
Area and sometimes affecting the vaginal wall,
Cervix, urethra and anus.
2. Painful blister form, rupture and drain leaving

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 Shallow ulcers that crust over and disappear after 2 – 6 wks.
3. Fever
4. Malaise
5. Anorexia
6. dysuria
7. dyspareunia

B. Recurrent:

1. pruritus
2. Burning sensation the genital area
3. Slight increase in vaginal discharge

Effects on pregnancy:
a. Spontaneous abortion
b. preterm labor
c. IUGR

 Fetal and neonatal effect:

a. microcephaly
b. Mental retardation
c. Patent ductus arteriosus

 Dx:

a. cytologic testing
b. b. pap smear

 Tx :
a. Zovirax ointment – to reduce viral shedding and
Healing time of lesion
b. Cleansing with betadine solution – to prevent
Secondary infection
c. Burow’s solution – to relieve discomfort
d. Keeping genital area clean and dry
e. Wear loose clothing and cotton underwear
f. Advised to abstain from sexual activity while lesion
are present
g. Bed rest

 Infection control measures :

a. Thorough handwashing
b. Gloves should be worn during contact with lesion or
Secretion
c. Discouraged from kissing the newborn
d. Instruction on genital hygiene

5. Condylomata Acuminata / Venerial warts

 Caused by human papillomavirus (HPV). This is transmitted through sexual contact.

 Incubation period: following exposure is 3 wks. – 3 yrs.

 S/Sx :
a. wartlike exposure on the vulva, vagina, cervix,
Rectum, buttocks and inner thigh
b. Chronic vaginal discharge
c. dyspareunia
d. pruritus
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  Dx : a. colposcopy
b. Direct visualization of growth
c. Biopsy

 Tx :
a. cryotherapy – to destroy the lesion
b. Knife excision
c. Application of podophyllin topically then wash it off 4
Hrs. after
d. Application ( for pregnant : trichloroacetic acid )
e. Laser therapy

6. Pediculosis pubis or pubic crab louse

 Caused by Phythirus thay lays eggs and attach to the hair shaft. It can be transmitted through shared
towels and bed linens.

 S/Sx :
a. Intense pruritus in areas covered by pubic hair
b. “ crabs” or brown – red spots may be noted in the
Underwear.

 Dx : microscopic exam. of the adult lice

 Tx :
a. Application of 1 % Permethrin cream for 10 mins.
Plus combing of the pubic hair with fine toothcomb.
b. Should be instructed to launder or dry clean all
Contaminated linens or clothing.

7. AIDS (Acquired Immune Disease Syndrome)

 Caused by HIV. The HIV enters the body through blood, blood products and other fluids such as semen,
vaginal fluid and breast milk. Although the virus has been isolated in urine, tears, CSF, lymph nodes, brain tissue
and bone marrow. Individuals generally develop antibodies and test ( + ) for HIV within 2 – 12 wks. after
exposure, although some people will take up to mos. To develop antibodies. A person with HIV ( + ) are usually
asymptomatic and remain for 5 – 7 yrs. or more .

 Lab. Test: ELISA (enzyme linked immunosorbent assay)

 Tx :AZT - antiviral agent

 Note: breastmilk may also transmit HIV

 SAFER SEX PRACTICES:

a. Abstinence e. frottage (body rubbing)
b. Hugging f. holding hands
c. Body massages g. fantasy voyeurism
d. Social kissing (dry) h. solo masturbation

 MODERATELY SAFE:
a. french kissing ( wet ) d. fellatio interruptus
b. Anal intercourse with condom e. cunnillingus
c. Vaginal intercourse with condom

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  UNSAFE SEX PRACTICE:
a. Anal intercourse without condom
b. Vaginal intercourse without condom
c. Fisting (manual - anal contact)
d. Fellatio with semen ingestion
e. Rimming (oral – anal contact)

COMPLICATION DURING LABOR AND DELIVERY

I. DYSTOCIA – refers to difficulty in labor characterized by abnormally slow progress of labor.

 Factors which causes dystocia ( 3 P’s )
1. Power 2. Passenger 3. Passage

 POWER – during the first stage of labor, the latent phase is said to be prolonged if it is > 20 hours in the nullipara
and > 14 hours in parous women.

 Factors that affect duration of latent phase:

a. excessive sedation
b. poor cervical condition
c. false labor

 In active phase, 2 abnormalities/ problems may present:

a. Protraction – slow rate of cervical dilatation or descent ( <1.2 cm/hr )
b. Arrest – complete cessation of cervical dilatation and descent.
b.1. Arrest of dilatation – 2 hrs. with no cervical change .
b.2. Arrest of descent – 1 hr. without fetal descent

 Factors contributing to both problems:

1. Excessive sedation
2. Fetal malposition

CATEGORIES OF DYSTOCIA

A. UTERINE DYSTOCIA
 Causes:
1. Uterine dysfunction/ dysfunctional labor – problem of inadequate force described or characterized by
abnormal uterine contraction that prevent normal progress of cervical dilatation, effacement and descent.

 Causes of uterine dysfunction:

a. Unwise use of analgesia
b. Poor fetal position
c. Pelvic bone contraction
d. Over distention of uterus ( multiple pregnancy, hydramnios)
e. Uterine anomalies and tumors
f. Extension of fetal head
g. Cervical rigidity – occur in elderly primi
h. Maternal exhaustion
i. Maternal age

 Classification of uterine dysfunction:

1.1 Hypotonic uterine dysfunction/ uterine inertia – denotes sluggishness of contraction. This is
occasionally occur during the latent phase of labor. The uterus is flaccid, weak contraction.

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  Causes:
a. malposition
b. fetopelvic disproportion
c. Overstretched uterus due to twin, big baby, hydramnios
d. Lax uterus due to grand multi.

 Maternal risk:
a. Intrauterine infection – due to vaginal exam.
b. Post-partal hemorrhage – due to inadequate uterine that has been present and may
persist after birth.
c. Maternal exhaustion

 Fetal risk:
a. Fetal and neonatal distress
b. Sign of sepsis

 Management:
1.amniotomy maybe done
2.intravenous fluid
3.oxytocin IV – to improve quality of uterine
Contraction
4.C/S – if fetal descent does not occur

1.2. Hypertonic uterine contraction – the intensity maybe

stronger and tend to occur frequently and uncoordinated
because of repolarization does not occur. There is no
pain free period. Patient maybe exhausted and express
concern about loss of control because of intense pain.

 Fetal – neonatal risk:

a. Fetal distress – occur early because contraction interfere with the uteroplacental
exchange.
b. Caput succedaneum – due to prolonged pressure of the fetal head
c. Cephalhematoma
d. Excessive molding

 Management:
a. Bed rest
b. Monitor progress of labor and FHB
c. Sedation
d. Administered adequate fluid
e. C/S – if fetal distress occur

 NOTE: Oxytocin is not administered because it is likely to accentuate the abnormal labor
pattern.

2. Pathologic retraction ring / Bandl’s ring – marked stretching and thinning of the lower uterine segment. It
occur at any stage of labor. When it occurs during the 1st stage, it is the result of uncoordinated contraction.
During 2nd stage, it is caused by obstetric manipulation. During 3rd stage, it is the result of administration of
oxytocin.

 Management:
a. C/S
b. Administration of IV morphine sulfate – to relieve the retraction ring.

3. Prolonged labor- labor lasting >24 hrs. The cervix fails to dilate within a reasonable period of time. Labor
was not considered prolonged unless 24 – 48 hrs. Had lapsed.

 Principle: “ Never let the sun set twice on a laboring woman.”

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  Principal causes:
a. CPD
b. Malpresentation
c. Malposition
d. Labor dysfunction
e. Cervical dystocia

 Other causes:
f. excessive use of analgesia / sedative
g. PROM in the present of uneffaced, closed cervix
h. Reduced pain tolerance

 Maternal risk:
a. Maternal exhaustion
b. Infection and hemorrhage from uterine atony

 Fetal risk:
a. Fetal distress
b. PROM – increase risk of infection
c. Prolapsed cord

 Management:
a. adminitration of oxytocin
b. amniotomy
c. intravenous fluid
d. rest and sedation
e. forcep delivery or C/S

4. Rupture of the uterus – involves the tearing of previously

intact uterine muscle or of an old uterine scar. Rupture during
pregnancy occur in the upper uterine segment and rupture
during labor occur in lower uterine segment.

 Causes:
a. prolonged labor f. VBAC
b. faulty presentation g. weakened C/S scar
c. multiple pregnancy
d. unwise use of oxytocin
e. traumatic maneuver – version or difficult forcep

 Classification:
2.1. complete – extend through the 3 muscle layer of uterus
2.2. incomplete – involves the whole myometrium but the peritoneum remain intact
2.3. spontaneous – occurs during labor
2.4. traumatic – associated with manipulation

 Signs and Symptoms:

a. sudden, severe pain during contraction
b. uterine contraction stops
c. hemorrhage
d. signs of shock – rapid weak pulse, falling BP, cold and clammy skin
e. change in abdominal contour
f. FHB falls

 Maternal risk: maternal mortality due to shock

 Fetal-neonatal risk:

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 a. fetal distress
b. fetal mortality

 Management:
a. medical mgt. of shock
b. STAT C/S then hysterectomy

5. Amniotic fluid embolism – occur naturally after oxytocin

induction with hypertonic uterine contraction. Presence of small tear in the amnion or chorion, the fluid may
leak the chorionic plate and enter the maternal circulation resulting to bronchospasm and cardiac failure. The
fluid can also enter at areas of placental separation or cervical tears.

 S/S:
a. Woman in strong labor suddenly sit up
b. Grasps her chest – due to dyspnea
c. Sharp pain
d. Pale and cyanotic
e. Death may occur in minutes

 Management:
a. O2 administration
b. Maintenance of cardiac output

 Maternal risk:
a. May experience respiratory distress
b. Increased maternal mortality

6. Hydramnios ( Polyhydramnios) – excessive amouont of

Amniotic fluid amounting to 2 liters. The cause is unknown.

 Maternal risk:
a. may experienced shortness of breath and edema in the lower extremities.
b. Intrapartal uterine contraction
c. Post partum hemorrhage

 Fetal-neonatal risk :
a. Fetal malformation
b. preterm birth

 Management:
a. Hospitalization is required
b. Removal of fluid – amniocentesis with the aid of UTZ

7. Oligohydramnios – defined as < normal amount of amniotic

Fluid. The cause is unknown.

 Diagnosed on UTZ – when the largest vertical pocket of amniotic fluid is 5 cm or less.
 Found in cases of postmaturity with IUGR secondary to placental insufficiency.

 Maternal risk: dysfunctional labor

 Fetal- neonatal risk:

1. During gestational period –
a. Fetal skin and skeletal abnormalities may occur because fetal movement is impaired as a
result of reduced amniotic fluid volume.
b. Pulmonary hypoplasia may develop because
c. there is less fluid available for the fetus to use during fetal breathing movements.
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 2. During labor and birth period – cord compression is more likely to occur because of the
lessened amount of fluid reduce the cushioning effect for the umbilical cord.

 Medical therapy:
1. During antepartal period - fetus can be assessed by biophysical profiles, NST and serial UTZ.
2. During labor – continuous EFM – to detect cord compression. ( by baseline bradycardia and / or
moderate or severe variable deceleration.)

B. FETAL DYSTOCIA
 Causes:
1.) Malpresentation
 Classification:
1. A. Breech presentation

 Complication to be anticipated:
a.1. perinatal morbidity and mortality
From difficult delivery
a.2. LBW from prematurity, growth
Retardation
a.3. Prolapsed cord
a.4. Placenta previa
a.5. Multiple fetuses

 Sub – classification:
a.1. Frank breech – lower extremities are flexed at
The hips and extended at the knee.
a.2. Complete breech – one or both knees are flexed
a.3. Footling breech – one or both feet is at the
Lowermost in the birth canal.

 Diagnosis:
1. abdominal exam. – leopold’s maneuver
LM 1 – hard, round, readily ballotable fetal head is
found to occupy the fundus.
LM 2 – indicates the back to be on one side of the
abdomen and the small parts on the other.
LM 3 – breech is movable above the pelvic inlet.
LM 4 – firm breech to be beneath the symphysis.

 FHB is in the lower quadrant and / or in the umbilicus.

2. Vaginal exam. – Both ischial tuberosities, sacrum and the anus are palpable.
3. X – ray and ultrasound

 Gen. methods of breech delivery / extraction:

a. Spontaneous breech delivery – the baby is expelled entirely spontaneously without any traction or
manipulation other than support of the baby.
b. Partial breech delivery – the baby is delivered spontaneously as far as the umbilicus.
c. Total breech delivery – the entire body of the baby is
extracted by the OB.
 Maneuvers applied:
a. Mauriceau’s maneuver – delivering the head through the used of operator’s index and middle
finger of one hand applied over the maxilla ( rationale: to flex the head while the fetal body
rests upon the palm of the hand and forearm ) and 2 fingers of the other hand then are
hooked over the fetal neck and grasping the shoulder. Downward traction is applied until the
sub occipital region appears under the symphysis. Gentle suprapubic pressure
simultaneously applied by an assistant helps keep the head flexed.

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 b. Prague maneuver – this is used in case the back of the fetus fails to rotate to the anterior. A
strong traction on the fetal legs is applied with 2 fingers of one hand grasping the shoulder of
the back down the fetus from below, while the other hand draws the feet up over the
abdomen of the mother.

c. Bracht maneuver – the breech is allowed to deliver spontaneously to the umbilicus.

d. Pinard maneuver – used in extraction of frank breech and maybe accompanied by modified
traction exerted by a finger in each groin and facilitated by a generous episiotomy. Two
fingers are carried up along one extremity to the knee to push it away from the midline.

 Maternal risk: prolonged labor

 Fetal risk:
a. head entrapment
b. high incidence of perinatal mortality – associated with trauma to the head
c. cord prolapsed – if BOW is ( - )

 Management:
a. perform version
 VERSION – turning the fetus; a procedure used to change the fetal position by abdominal or
intrauterine manipulation.

 Indication: if a breech or transverse presentation is diagnosed in the last week of pregnancy.

 Types of version:
a. 1.external version – usually done after 37th wks. gestation. This is an external
manipulation of the maternal abdomen.

Requirement:
a. presenting part is not engaged
b. normal amount of amniotic fluid
and intact BOW
c. no sign of fetal distress
d.the woman is not obese

 Contraindication:
a. ruptured membrane
b. ( + ) of uterine contraction
c. IUGR
d. Placenta previa
e. Previous C/S

a.2.internal version – turning the fetus by inserting a hand into the uterine cavity. This is used
only with the 2nd twin during a vaginal delivery.
b.fetal monitoring
c. C/S – if version is unsuccessful

2.A. Face presentation

 Occur most frequently in multis, preterm birth and in cases of anecephaly.

 Maternal risk : prolonged labor

 Fetal risk:
a. may develop caput succedaneum
b. edema of the face after birth
c. infection

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  Management:
a. vaginal delivery if no evidence of fetal distress
b. C/S – in case of CPD

3.A. Brow presentation

 Occur more often in multi. due to lax abdominal and pelvic musculature.

 Maternal risk : perineal laceration may extend

into the rectum if vaginal delivery.

 Fetal risk:
a. increase fetal mortality
b. trauma – neck compression
- damage trachea and larynx

 Management:
a. forcep delivery
b. C/S – if fetal distress is suspected
4.A. Shoulder presentation or transverse lie
 The infant’s long axis lies across the woman’s abdomen and on inspection, the contour of
the maternal abdomen appears widest from side to side.

 Etiology:
a. grandmulti with lax uterine musculature
b. preterm fetus
c. obstruction – placenta previa; neoplasm
d. hydramnios
e. contracted pelvis

 Diagnosis:
a. Leopold’s maneuver
LM 1 – no fetal pole is detected in the fundus
LM 2 – ballottable head is found in one iliac fossa and the breech in the other.
LM 3 – negative
LM 4 – negative
 FHB are heard just below the midline of umbilicus.

b. vaginal exam. – in early stages of labor, the side of the thorax may be recognized.

 Maternal risk:
a. uterine rupture
b. infection in case of prolonged labor

 Fetal risk :
a. prolapsed cord
b. prolapsed fetal arm
c. may die from asphyxia and trauma

 Management:
C/S

5.A. Compound presentation

 Occur when the pelvic inlet is not totally occluded by the primary presenting part.

 Maternal risk : laceration

 Management: C/S
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 6.A. Cord prolapsed
 When the umbilical cord precedes the fetal presenting part.

 Occult cord prolapse – when the umbilical cord lies besides or just ahead of the fetal
head.
Most likely to occur in :
a. malpresentation
b. LBW
c. Multipara
d. Multiple gestation
e. Presence of long cord

 Fetal risk:
a. umbilical cord compression
b. bradycardia and persistent variable deceleration may develop

 Management:
a. put patient in bed STAT and in T – berg position – because the possibility of cord
compression is high and reduce pressure on the cord.
b. Monitor FHB
c. Apply a warm, saline saturated OS on the cord
d. C/ S

2.) Multiple Pregnancy

 Incidence / frequency of twins:

a. race d. parity
b. heredity e. fertility drugs
c. age

 Division of fertilized ovum at various early stages of development as follows ( Genesis of monozygotic
twin):
a. If the fertilized ovum divides within the 1st 72 hours past fertilization, the twin will be diamniotic,
dichorionic monozygotic twin.

b. If the division occurs from the 4th – 8th day past fertilization, the embryos will develop each in
separate amniotic sacs termed as diamniotic , monochorionic, monozygotic twin.

c. If the division happens after the 8th day, the twin will share both common amniotic sac termed
as monoamniotic, monochorionic, monozygotic twin.

d. If the division is even later, that is after the

Embryonic disk is formed, cleavage is incomplete and conjoined twin is formed.

 Etiology :
a. Fraternal – occur from 2 separate ova ( dizygotic ) and they maybe the same sex or different
sexes. – diamniotic, dichorionic ( 2 amnion and chorion )
b. Identical – occur from 1 fertilized ovum ( monozygotic ) and are always of the same sex.

 Complication / Maternal risk:

1. Antenatal period
1.a. spontaneous abortion – are more common,
possibly because of genetic defects or poor
placental implantation or development.

1.b. maternal anemia – occurs because the

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 maternal system is nurturing more than one
fetus.
1.c. increase incidence of PIH – as a result from
oversized uterus and increase amount of
placental hormones.
1.d. 3rd trimester bleeding from placenta previa and
abruptio placenta occurs more frequently.

2. During labor
2.a. uterine dysfunction – due to over stretched
myometrium
2.b. abnormal fetal presentation
2.c. preterm labor
3. perinatal mortality
4. LBW
5. Uterine atony
6. Hydramnios

 Medical therapy:
a. comprehensive prenatal
b. ultrasound – to assess the growth of each fetus
c. bed rest in lateral position – enhance uterine placental- fetal blood flow and decrease the risk of
preterm labor.
d. Non stress test – at 30 – 34 wks AOG
e. During intrapartal – anesthesia and x – matched blood should be readily available.
- electronic fetal monitoring

f. presence of complication requires C/S

g. vaginal birth is suggested if no fetal distress

3.) Malposition

4.1. Persistent occiput posterior position

 Failure of spontaneous rotation
 Narrow pelvis

 Maternal risk: may suffer 3rd or 4th degree

perineal laceration

 Management:
a. vaginal delilvery is possible as follows:
1. await spontaneous birth
2. forcep – assisted
3. forcep rotation using Scanzoni maneuver or manual rotation to OA

b. C /S – in case of CPD

4.2. Persistent occiput transverse position

 Maternal risk: maternal soft tissue damage due
to manipulation

 Management: manual rotation anterior or

posterior and forcep delivery
follows.

4.) Development of the fetus

4.1. Fetal macrosomia –BW > 4000 gms.

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  Factors to be considered:
a. large size of the parents especially the mother
b. multiparity
c. maternal diabetes
d. maternal obesity
e. prolonged gestation
f. previous delivery of an infant weighing >4000g

 Maternal risk:
a. may lead to dysfunctional labor – due to distention of the uterus
b. increase incidence of post partum hemorrhage
c. increase chance of uterine rupture
d. increase incidence of perineal laceration

 Fetal risk:
a. asphyxia
b. brachial plexus injury – due to improper or excessive traction applied to the fetal head.
c. Shoulder dystocia – difficulty in the birth of shoulder or impaction of the shoulder.

 Management for shoulder dystocia:

c.1. a moderate suprapubic pressure by an assistant while downward traction is
applied to the fetal head.
c.2. Mc Robert’s maneuver
c.3. Wood’s corkscrew maneuver – the hand
is placed behind the posterior shoulder
of the fetus. The shoulder is then
rotated progressively 180 degrees so
that the impacted anterior shoulder is
released.

 Management:
a. ultrasound or x – ray pelvimetry
b. use of Mc Robert’s maneuver
c. enlarge the episiotomy
d. assess FHB for fetal distress

4.2. Hydrocephalus
 Excessive accumulation of cerebrospinal fluid in the ventricles of the brain with consequent
enlargement of the cranium. The volume of fluid is usually between 500 – 1,500 ml.

 Maternal risk:
a. obstruction of labor
b. uterine rupture may occur if the uterus is allowed to continue contracting.

 Fetal risk: outlook of the fetus is poor

 Diagnosis: ultrasound

 Management:
a. cephalocentesis – removal of CSF
b. C/S

4.3. Conjoined twin / incomplete twinning

 Commonly referred as siamese twins.
 If twinning is initiated after the embryonic disc and the rudimentary amniotic sac have been
formed, and if division of the embryonic disc is incomplete, conjoined twins result.

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  Sites:
a. thoracopagus – shared body site is anterior
b. pyopagus – posterior
c. craniopagus - cephalic
d. ischiopagus – caudal

 3 groups:
a. incomplete formation at the upper or lower half of the body ( diprosopus dipygus )
b. twins that are united at the upper or lower end of the body (craniopagus, pygopagus)
c. Double monster – united at the trunk ( dicephalus )

 Diagnosis: ultrasound – during mid pregnancy

 Management: a vaginal delivery is possible although dystocia is common and if the fetuses
are mature, traumatic delivery may experience.

4.4. Anencephaly
 Condition in which the fetal cerebrum and cranium fail to develop.
 Appearance of the fetus sometimes referred to as “ anencephalic monster”
 Face is prominent with protruding eyes and cranial vault is absent.
 Cause is unknown
 Commonly accompanied by hydramnios
 Diagnosis can be confirmed by UTZ and amniocentesis.

 Maternal implication:
 tend to be prolonged and induction of labor is difficult – uterus may not be responsive to
oxytocin.

 Nursing responsibilites:
1. Provide physical and emotional support
2. Provide information sensitively
3. Acknowledge the loss and grieving of family members

C. PELVIC CONTRACTION
 Causes:

1. Contracted pelvic inlet

 Narrowing of the AP diameter < 11 cm or of a maximum transverse diameter < 12cm.

 Maternal effect:
a. abnormal cervical dilatation
b. danger of uterine rupture and pathologic retraction ring
c. intra partum infection

 Fetal effect:
a. caput succedaneum
b. fetal head molding – can result in skull fracture or intracranial hemorrhage
c. cord prolapse – if membranes ruptured and fetal head has not entered the inlet

 Maternal risk:
a. prolonged labor in the presence of CPD
b. PROM
c. Uterine rupture

 Management: C /S

2. Contracted mid pelvis

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  When the sum of the interspinous and posterior sagittal diameter falls to 13.5 cm or below.

 Management: forcep delivery

3. contracted pelvic outlet

 Diminution of the interischial tuberous diameter to 8 cm or less.

D. SOFT TISSUE ABNORMALITIES OF THE REPRODUCTIVE TRACT

1. VULVAR ABNORMALITIES
1.1. Edema – venous thrombosis and hematoma may cause edema and significant pain and make an
episiotomy difficult to perform but dystocia rarely results.

1.2. bartholin abcess – cause pain and discomfort and can be starting point of puerperal infection.

2. CYSTOCELE
 Protrussion of the bladder downward into the vagina that develops when supporting structure in the
vesicovaginal septum are injured.
 Anterior wall relaxation gradually develops often after several babies. When the woman stands, the
weakened anterior vaginal wall cannot support the weight of the urine in the bladder, the vesicovaginal
septum is forced downward.
 It is recognized as bulging of the anterior wall of vagina.

3. RECTOCELE
 Herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal
septum.
 It can cause disturbance in bowel function, the sensation of “ bearing down”.

4. DISPLACEMENT
4.1. uterine prolapse – occurs when the cardinal ligaments that supports the vagina and uterus donot
return to normal after delivery and when the relationship of the axis of the uterus to that of the vagina
is altered.
 Always accompanied with cystocele and rectocele.

 Tx: transvaginal surgical correction

4.2. retroversion
 most common displacement
 maybe congenital or a sequel to childbirth

4.3. lateral displacement

 accompanied by large ovarian tumor, inflammation

5. Presence of tumor

6. MALDEVELOPMENT /ABNORMAL DEVT. OF UTERUS

 Etiology:

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  During fetal development, the female reproductive tract is formed by the fusion of the 2
mullerian ducts. Anomalies arise primarily from the alteration of the fusion process. Failure of the
duct to fuse normally results in 2 partially or completely separated tracts.

 Structural abnormalities:
10.1 Uterine abnormalities
 4 types:
a. Septate uterus – appears normal from the exterior, but it contains a septum that
extends partially or completely from the fundus to the cervix, dividing the uterine
cavity into 2 separate compartment.
b. Bicornuate uterus – roughly Y –shaped. The fundus is notched to various depth
and the patient may even appear to have a “ double uterus” however, there is
only 1 cervix.
c. Double uterus – results from lack of midline fusion, and 2 complete uterine, each
with its own cervix are formed.
d. Uterus didelphys – when both are fully formed.
e. Hemiuterus – results when one mullerian duct fails to develop during embryonic
growth, resulting in 1 uterine cavity and 1 oviduct.

 Malformation of the uterus may cause difficulty when pregnancy occurs. The uterus may not
be able to stretch sufficiently to accommodate the growing fetus.
 If the woman has abnormal external genitals – surgical reconstruction of abnormal tissue and
construction of functional vagina may permit normal intercourse.
 Surgical intervention depends entirely on the anatomic devt.

 Problems may arised:

a. abortion d. pathologic retraction ring
b. preterm labor e. uterine rupture
c. uterine dysfunction

10.2 Cervical abnormalities

 Types:
a. Septate cervix – consists of a ring of muscular tissue partitioned by a septum that
either extends downward from the uterus or upward from the vagina.
b. Double cervix – 2 separate cervices in 1 uterus.
c. Single hemicervix / half cervix – results from incomplete and asymmetrical devt. in
which 1 mullerian duct matures.

 May affect labor and birth depending on the ability of the cervix to dilate and efface.

6.3. Vaginal abnormalities

 vaginal septa – most common
 do not present serious problem
 they are easily accessible and can be removed surgically

 Tx:
a. surgical tx for structural abnormalities
b. C / S

 Nursing Responsibilities:
a. assessment and close monitoring of progress of labor
b. monitor for sign of dystocia

II. Precipitate labor – extremely rapid labor that last for <
3 hrs.
 Causes:
a. Abnormal low resistance in maternal tissues
b. Strong uterine contraction
c. Lack of pain sensation
d. multiparity

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 e. oxytocin overdose
f. Large pelvis

 Maternal risk:
a. severe laceration
b. possibility of uterine rupture
c. post partum hemorrhage
d. amniotic fluid embolism

 Fetal-neonatal risk:
a. subdural hemorrhage
b. increased intracranial pressure
c. injury secondary to fall
d. laceration or rupture of the cord

 Management:
a. Allow the baby to be born and to catch the baby
b. Do not hold the baby back nor “ lock” the mother’s leg in an attempt to delay delivery – may result in
damage to the maternal soft part and baby’s brain.

 Precipitate delivery –refers to sudden, unexpected and unprepared delivery under unsterile condition.

III. Fetal distress

 When the oxygen supply is insufficient to meet the physiologic demands of the fetus.

 Contributing factors:
a. Cord compression
b. uteroplacental insufficiency associated by pre existing maternal / fetal disease.

 Signs:
a. Changes in FHT
b. meconium stained amniotic fluid
c. Late or severe variable deceleration or progressive acceleration – indication of hypoxia

 Fetal risk:
a. Fetal hypoxia which may lead to mental retardation or cebreral palsy
b. Fetal demise (fetal death )

 Management:
a. O2 inhalation
b. Positioned patient
c. Electronic fetal monitoring
d. D/C oxytocin

IV. PRE TERM LABOR

 Labor occurs between 20 – 37th wks of pregnancy.

 Causes:
1. Maternal factors
a. Cardiovascular or renal disease
b. Diabetes
c. PIH
d. Abdominal surgery during pregnancy
e. Uterine anomalies
f. Cervical incompetence
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 g. DES exposure
h. Maternal infection

2. Fetal factors
a. Multiple pregnancy
b. hydramnios
c. Fetal distress

3. Placental factors
a. Placenta previa
b. abruptio placenta

Risk factors for spontaneous pre term labor:

a. Multiple gestation
b. hydramnios
c. Febrile illness
d. Bleeding after 12 wks
e. Maternal medical disease
f. Low socioeconomic status
g. Cigarette smoking > 10 sticks/ day
h. Previous preterm birth

 Maternal risk:
a. psychologic stress factors related to the concern for her unborn child
b. Physiologic maternal risk related to possible medical tx such as tocolysis and prolonged bed rest.

 TOCOLYSIS – the use of therapeutic intervention in an attempt to stop labor.

 TOCOLYTIC DRUGS – drugs used to stop labor .

 Fetal- neonatal risk:

 maturational deficiencies – fat storage, heat regulation, immaturity of organ system.

 S/S of pre term labor:

1. uterine contraction that occur every 10 mins. or less with or without pain.
2. Change in braxton – hicks contraction from irregular to regular pattern.
3. Mild menstrual – like cramps felt low in the abdomen
4. Constant or intermittent feelings of pelvic presure
5. Rupture or membrane
6. Low, dull backache, which maybe constant or intermittent
7. Sudden increase in vaginal discharge
8. Abdominal cramping with or without diarrhea

 Management:
a. Avoid hypoxia
b. Avoid depressing the fetal respiratory center with excessive analgesic drugs
c. Use epidural analgesia
d. Use C/S particularly in breech presentation
e. Reduce trauma to the fetus particularly the skull in vaginal delivery

V. POST TERM / POST DATE/ POST MATURITY

 Extend >294 days or 42 wks.

 Cause is unknown
 Occur more frequently between ages 15 and 20 and over 35

 Etiologic factors:
 Hormonal changes of estrogen, progesterone and prostaglandin

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  Maternal risk:
a. Increase incidence of operative birth
b. oligohydramnios may be present

 Fetal – neonatal risk:

a. Risk of umbilical cord compression
b. macrosomia
c. During labor, increase incidence of FHR baseline changes
d. meconium – stained
e. Fetal distress

 Management:
1. Assess client using NST, BPP weekly
2. Induction of labor

VI. INTRAUTERINE FETAL DEATH/DEMISE (IUFD)

 Fetal death is determined by the point in gestation when death occurs.
 Missed abortion – when the fetus dies before 20 wks of gestation and is not aborted spontaneously.
 Fetal death – occurs after 20 wks gestation and may be used when labor does not begin with in 48 hrs of
death.

 Diagnosis:
1. (-) fetal movement
2. (-) FHB
3. Uterine growth ceases
4. Uterine size decrease
5. Fetal heart movement cannot be visualized by UTZ
6. x – ray detected by the appearance of intravascular or intra abdominal fetal gas ( Robert’s sign )

 Etiology:
 associated with severe maternal DM, pre eclampsia, placenta previa and umbilical cord accident.

 Management:
A. At 12 wks.
1. Confirmation of diagnosis – to diagnose fetal death ASAP through UTZ
2. D/C of uterine contents – to evacuate
3. Prescription of analgesic
B. 13 – 28 wks
1. Confirmation
2. Induction of labor after 3 wks of fetal death
3. Labor and delivery of product of conception
4. Prescription of analgesic and methergin
5. Uterine curettage – to ensure removal of all tissue
6. Cervical inspection for trauma
C. > 28 wks.
Same as above

POST PARTUM COMPLICATION

1. HEMORRHAGE – blood loss > 500 ml during the 1st 24 hrs. after delivery
 Normal blood loss for NSD – 250 – 350 ml.
 Normal blood loss for C/S - 700 – 1000 ml.

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  Classification of hemorrhage:
1.1. Early post partum hemorrhage – or immediate post partal hemorrhage.
 Occur within the 1st 24 hrs. After birth.

 Causes:
A. Uterine atony - failure of the uterus to contract adequately. This is the most common
cause of early post partum hemorrhage.

 Predisposing factors:
a.1. overdistention of the uterus
a.2. Dysfunctional labor
a.3. Excessive analgesia during labor or
Prolonged anesthesia after sedation
a.4. oxytocin use
a.5. Trauma due to obstetric procedure or
Manipulation
a.6. grandmultiparity

 Sign and symptoms:

a. Boggy, relaxed uterus
b. Dark bleeding
c. Passage of clots

 Management:
a.1. Massage the uterus – initial action
a.2. Ice compress
a.3. oxytocin administration
a.4. emptying the bladder
a.5. Bimanual uterine compression – if
Bleeding is excessive
a.6. O2 via mask
a.7. Check the cervix and vagina for Laceration

a.8. hystetrectomy – last resort

B. Laceration in the perineum, vagina or

Cervix

 Can be detected when bright red bleeding persists in the presence of firmly
contracted uterus.

 Sign and symptoms:

a. firm fundus
b. oozing of bright red blood

 Management:
 episiorrhaphy

C. Retained placenta – the most common cause is due to massage of the fundus prior to
placental separation.

 Management:
c.1. manual removal of the placenta

c.2. uterine massage

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 1.2. Late post partum hemorrhage - generally occurs 1 – 2 wks after delivery and most often results of
abnormal involution of the placental site.

 Predisposing factors:
 retained placental fragments

 Management:
 curettage

 Signs of post partal hemorrhage:

1. Excessive or bright red bleeding
2. Boggy fundus that does not respond to massage
3. Abnormal clots
4. Any unusual pelvic discomfort or backache
5. Persistent bleeding in the presence of firmly contracted uterus
6. Rise in the level of the fundus of the uterus
7. Increase pulse rate or decrease BP
8. hematoma formation or bulging/ shiny skin in the perineal area
9. Decrease level of consciousness

2. HEMATOMA / PUERPERAL HEMATOMA – occur as a result of injury to a blood vessel, often without
noticeable trauma to the superficial tissue.

 Predisposing factors:
a. PIH
b. Genital varicosities
c. Increase vascularity
d. Use of pudendal regional anesthesia
e. Precipitate labor
f. Prolonged 2nd stage of labor
g. Forcep – assisted birth

 Classification:
2.1.Vulvar - most opften involve branches of
the pudendal artery including the posterior
rectal, transverse perineal or posterior labial
artery.
2.2.Vaginal – may involve the descending branch
of the uterine artery.
2.3.Vulvovaginal
2.4.Retroperitoneal

 Management:
a. small vulvar hematoma may be treated with the application of ice pack.
b. Large hematoma require surgical intervention
c. Antibiotic
d. Vaginal packing

3. INFECTION / PUERPERAL INFECTION - refers to

Infection of the reproductive tract associated with childbirth that can
Occur anytime from birth to 6 wks post partum.

 Predisposing factors:
A. Antepartum
a. Anemia
b. Nutrition
c. Sexual intercourse

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 B. Intrapartum
a. Bacterial contamination
b. Trauma
c. Blood loss
d. PROM
e. Excessive i.e. during labor

 Types of infection :
3.1. Lesion of the perineum, vulva, vagina and cervix
 is a localized infection of repaired laceration or
episiotomy.
 most common puerperal infection.

 Clinical sign: red, brawny and swollen

 Necrotizing fasciitis – an infection of the superficial fascia and subcutaneous tissue arising from
an episiotomy site.

 Early sign:
 erythema , edema and induration at the
episiotomy site with later devt. Of skin
Discoloration.

 Common symptoms of lesion of the perineum:

1. Local pain or pelvic pain
2. dysuria
3. Fever
4. Foul – smelling lochia
5. Chills
6. Rapid pulse

 Tx:
1. Analgesic
2. Antibiotic therapy
3. Stitches should be removed
4. sitz bath

3.2.Endometritis / metritis
 After placental expulsion, the placental site provides an excellent culture medium for bacterial growth.

 Clinical sign:
a. Fever
b. Abdominal pain or tenderness on one or both side of abdomen
c. After pain
d. Foul smelling lochia

 Tx: analgesic

 Nursing care:
1. Place patient in fowler’s or semi – fowler’s position
2. Fluid intake 3000 – 4000 ml ( if not contraindicated )
3. Provide high caloric foods

3.3 Peritonitis – uterine infection may extend by way of the

lymphatics to reach the abdominal cavity.
 rarely seen but may encountered with infection following c/s when there is uterine incisional necrosis
and dehiscence.

 Clinical sign:
a. Pain may be severe
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 b. Marked bowel distension

 Tx:
a. IVF
b. Broad – spectrum antibiotic
c. Should be treated surgically

3.4.Mastitis – inflammation of the breast generally caused by

Staphylococcus aureus and primarily seen in breastfeeding
Mothers.

 Sign:
a. Puerperal fever c. chills
b. Engorged breast d. abcess ( if untreated )

 Classification:
4.3.1. Milk stasis – a mild, short – lived condition, usually without fever and not requiring
antibiotic.
 Causes:
a. Tight clothing
b. Missed feeding
c. Poor support of pendulous breast

4.3.2. Non infectious inflammation of the breast

 last for several days. It is represented by more severe inflammatory symptoms.

4.3.3. Infectious mastitis – a more serious infection with fever, headache, flulike symptoms
and warm, reddened, painful area of the breast.

 Tx:
a. Bed rest
b. Increased fluid intake
c. Supportive bra
d. Feeding the baby frequently
e. Local application of heat
f. Analgesic

 For infectious mastitis:

a. Antibiotic
b. Surgical drainage
c. Breastfeeding is dicontinue temporarily

4. SUB INVOLUTION
 Occurs when the uterus fails to follow the normal pattern of involution.

 Causes:
a. Retained placental fragments
b. Infection

 Clinical sign: big uterus with vaginal bleeding and clots

 Tx:
a. Methergin 0.2 mg every 4 hrs. for 24 – 48 hrs.
b. when metritis is present – antibiotics
c. curettage – if treatment is not effective

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